[Error of dialysis concentrate: a cause of severe metabolic acidosis not detected by certain generators].
The authors report three cases of severe metabolic acidosis caused by errors of concentrate during hemodialysis "acide concentrate" instead of "acetate" bath. Symptoms began towards the second hour of the session with sickness and important vomits. Blood chemistries showed in all severe acidosis with hyperchloremia and hyperkaliemia while proper conductivity was obtained without alarm. Reconnection on dialysis with a correct bath was able to improve the above mentioned abnormalities. In vitro errors with different types of concentrates and machines have been simulated and the safeguards are discussed. The pH meter with alarm is proposed for all proportioning equipments, not only on "bicarbonate" generator but also on "acetate" delivery systems and especially in centers where these two types of concentrates are prescribed. Being vigilant remains nevertheless the best safeguard against human errors.
Cao Huu
T
T
Service de Néphrologie, CHRU de Nancy-Brabois, Vandoeuvre-les-Nancy.
Jonon
B
B
Chanliau
J
J
Barre
P
P
Kessler
M
M
D000085:Acetates; D000138:Acidosis / Q000209:etiology*; D000328:Adult; D001639:Bicarbonates; D015314:Dialysis Solutions / Q000009:adverse effects*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008875:Middle Aged; D006435:Renal Dialysis / Q000009:adverse effects*
D000085:Acetates; D001639:Bicarbonates; D015314:Dialysis Solutions
Erreur de concentré de dialyse: une cause d'acidose métabolique sévère non détectée par certains générateurs.