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...potential so the authors' institutions carried out investigations to find any factors common to all patients. Amongst the potential causes ruled out, were water quality, dialysis machines and dialysers (new and re-used). In all cases the most likely cause appeared to be a narrowing of the bloodlines, though it must be mentioned that the manufacturer's analysis of these did not offer any evidence of this. The authors thus kept an open mind about the actual root cause of the incidents.

Damage to red blood cells (RBC) occurs in all dialysis sessions to some degree, due to the nature of the treatment. Possibly the most important point made by the authors, was that there were no obvious signs of hemolysis in the extracorporeal circuit, in effect, the hemolysis was hidden! Only towards the end of dialysis did any symptoms become apparent, the most common being abdominal pain. Nothing during the dialysis treatments seemed to predict the severity of the hemolysis and the authors were grateful that no fatalities resulted.

HEMOLYSIS IN DIALYSIS: A HISTORICAL INSIGHT

Susan K. Hansen provided a personal description of haemodialysis in the 1960's and pointed out that even with the technology available then, hemolysis was quite rare. "My career in dialysis started in 1965--a very different world. In the US at that time nurses were not allowed to put anything into the bloodstream (i.e., meds, start IVs, etc) so they couldn't do dialysis. We dialyzed two patients at once, a total of ten patients for two treatments each per week. Hemolysis was uncommon even then but it happened. Blood pumps were cruder, shunt flows could abruptly vary during treatment and it was possible to forget to weigh and add one of the dialysate chemicals. There were no dialysis monitoring systems and the operator had to visually monitor the bloodlines, dialyser and dialysate throughout the six-hour treatment. Fortunately, significant hemolysis is very obvious in the venous drip chamber and the large blood volumes of these early dialysers meant that the blood circuit was primed with two units of bank blood before each treatment. Discontinuing the treatment, and discarding the hemolysed extracorporeal circuit, whilst not desirable, had no serious clinical sequellae. In my experience, the first sign of hemolysis was that the blood in the venous line or drip chamber turned strangely transparent--although it was the same red as before--you could see right through it! Another sign was when we did Lee-White clotting times (every half hour) and the blood in the tube was noted to be oddly translucent. We were especially vigilant after dialysate batch changes (we dialyzed with a Travenol 100 L tank unit), even though we double-checked the chemicals pre-bath change."

It appears that, although the risks of hemolysis were undoubtedly higher in the 1960's, the close scrutiny afforded to all dialysis treatments minimised its occurrence or at least ensured it was quickly detected and acted upon.

POTENTIAL CAUSES OF HEMOLYSIS IN HAEMODIALYSIS

Haemodialysis (HD) is a technically demanding treatment and there are inherent risks in the process. Though HD machines are designed to detect and safely manage many of these risks the technology is far from perfect. One such risk...

NOTE: All illustrations and photos have been removed from this article.



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