Exsanguination of a home hemodialysis patient as a result of misconnected blood-lines during the wash back procedure: a case report.

BMC Nephrology
Kerryanne AllcockMark R Marshall

Abstract

Home hemodialysis is common in New Zealand and associated with lower cost, improved survival and better patient experience. We present the case of a fully trained home hemodialysis patient who exsanguinated at home as a result of an incorrect wash back procedure. The case involves a 67 year old male with a history of well controlled hypertension and impaired glucose tolerance. He commenced on peritoneal dialysis in 2006 following the development of end stage kidney failure secondary to focal segmental glomerulosclerosis. He transferred to hemodialysis due to peritoneal membrane failure in 2010, and successfully trained for home hemodialysis over a 20 week period. Following one month of uncomplicated dialysis at home, he was found deceased on his machine at home in the midst of dialysis. His death occurred during the wash back procedure performed using the "open circuit" method, and resulted from misconnection of the saline bag to the venous end of the extracorporeal blood circuit instead of the arterial end. This led to approximately 2.3L of his blood being pumped into the saline bag resulting in hypovolaemic shock and death from exsanguination. Despite successful training, critical procedural errors can still be made by patien...Continue Reading

References

Jun 9, 2000·Kidney International·D O McGregorK L Lynn
Jun 17, 2005·Nephrology·Christopher R Blagg
Jun 17, 2005·Nephrology·Kelvin L Lynn, Adrian L Buttimore
Jul 20, 2007·International Journal of Health Care Finance and Economics·Toni Ashton, Mark Roger Marshall
Jul 22, 2008·Hemodialysis International·Carmel M HawleyCarolyn Van Eps
Aug 6, 2011·American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation·Mark R MarshallStephen P McDonald

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Citations

Sep 3, 2013·American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation·Ben WongRobert P Pauly
May 1, 2015·Hemodialysis International·Robert P PaulyMark R Marshall
Jun 10, 2015·Journal of Biomedical Informatics·Atish RajkomarAnn Blandford
Dec 3, 2014·American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation·Karthik K TennankoreChristopher T Chan
Nov 8, 2014·Clinical Journal of the American Society of Nephrology : CJASN·Alan S Kliger
Oct 19, 2019·BMC Nephrology·Damien AshbyMartin Wilkie
Jul 26, 2019·Clinical Journal of the American Society of Nephrology : CJASN·Ali Ibrahim, Christopher T Chan
Feb 21, 2021·Seminars in Dialysis·Ankur Gupta, Deborah Zimmerman

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