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Lessons from Haemodialysis-Associated Haemolysis in Northern Ireland

Learn from a case study of haemolysis in haemodialysis patients in Northern Ireland, highlighting causes, symptoms, and actions taken to protect patient safety.

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Lessons from Haemodialysis-Associated Haemolysis in Northern Ireland

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  1. Haemodialysis Associated Haemolysis Lessons from the Northern Ireland Cluster Dr Henry Brown

  2. Background Causes of Haemolysis Dialysate problems eg hypotonicity Water contamination Faulty roller clamps Kinking of Lines Construction faults with lines

  3. Index Case 44 year old female ESRD 2 o PCKD on haemodialysis for 42 months During routine HD session developed nausea, vomiting, abdominal pain, hypertension Haemolysis – red supernatant, raised LDH, fall in Hb of 3g/dl Inability of lab to report K+ and other common variables Raised amylase, subsequent radiological evidence of acute pancreatitis Symptoms settled quickly

  4. Other Cases More than one Dialysis Unit A Problem to be Addressed

  5. Actions taken Internal Review Meeting with Industry & NIAIC Investigation Measures to protect patient safety Search for other cases MHRA visit

  6. August 2008 –May 2009 Trigger case

  7. Distribution of Cases 3 4 6 3

  8. Possible explanation Contaminated water/dialysate NO Damaged/faulty lines NO NO Patient related factors

  9. Kink Arterial Port Kidney Venous Port

  10. Learning points • Potential cause of significant morbidity / mortality • May go unrecognised • Aetiology may be difficult to identify • Importance of staff vigilance • Importance and benefit of clinical networks

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