11/08/09

Haemolysis and learning from dialysis incidents

There have been two further cases of haemolysis reported from the same unit which are definitely associated kinking of the line going into the top of the dialyser. This cause has been previously reported in the literature (Rambausek M. et al. NDT 1995; 10: 2141-43) as has kinking of the line between the dialyser and the compliance chamber (Hudson S. et al. NDT 1993; 8: 477-479). Some dialysis machines have a slot on the dialyser clamp which holds the line and prevents kinking.

Read guidance on investigation of HD-associated haemolysis (one page doc)

There have been two further cases of haemolysis reported from the same unit which are definitely associated kinking of the line going into the top of the dialyser.  This cause has been previously reported in the literature (Rambausek M. et al. NDT 1995; 10: 2141-43) as has kinking of the line between the dialyser and the compliance chamber (Hudson S. et al. NDT 1993; 8: 477-479).  Some dialysis machines have a slot on the dialyser clamp which holds the line and prevents kinking.

In addition another unit has reported a patient who has had 4 episodes of haemolysis over a 15 month period. Autoimmune haemolysis has been ruled out, and there have been no dialysis-related factors identified, either water sterilisation of dialysis line kinking. No other cases of haemolysis have occurred in this unit, so the cause in this patient is likely to be a patient-related condition, as yet unidentified.

We would be grateful if renal units could continue to report any further episodes of haemolysis associated with haemodialysis as patient safety incidents to the NPSA and provide more detailed clinical information to the Renal Association for wider learning.

Please submit comments, solutions, and personal experience to Dr. Paul Rylance, Renal Unit, New Cross Hospital, Wolverhampton, WV10 0QP,  Paul.Rylance@rwh-tr.nhs.uk

Full message – Read guidance on investigation of HD-associated haemolysis (one page doc)