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About Preventing Dangerous
Hemodialysis Catheter Disconnections
Ten minutes after a patient began receiving a hemodialysis
treatment, his venous blood line separated from the catheter.
Shortly after the venous blood line was clamped, the patient
complained of shortness of breath. His respirations were labored
at a rate of 28 to 32 breaths/minute. He was immediately placed on
his left side in Trendelenburg's position, started on 10
liters/minute of oxygen by face mask, and transported to the
hospital. Despite these measures, he died of an air embolism.
What went wrong?
An implanted or nonimplanted
hemodialysis catheter can be used as a "bridge" device until the
patient's arteriovenous graft or native fistula is ready to be
used. If the hemodialysis catheter inadvertently separates from
the venous blood line, the patient can suffer an air embolism or
quickly lose a large amount of blood.
When a catheter separates, the
hemodialysis machine's alarm doesn't always go off. Its venous
pressure monitor triggers an alarm when the venous blood line
falls below the limit set by the user.
A patient can lose 200 to 250 mL/minute
of blood when a catheter separates. The rate of blood loss varies
depending on the rate at which the blood is being pumped through
the hemodialysis machine.
The Food and Drug Administration
(FDA) has received adverse event reports describing hemodialysis
catheters that have separated, leaked, cracked, torn, or broken,
leading to infection, air embolism, blood loss, additional
surgery, or death.
(
http://www.fda.gov/cdrh/medicaldevicesafety/
tipsarticles/catheter.html )
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