Ultrafiltration controller failing: a case report.
The development of ultrafiltration controllers has been a major technical progress in haemodialysis. We report the failure of such a controller where the alarm failed to actuate, resulting in a patient weight gain of 3.1 kg over a full dialysis session, instead of a programmed 4.5 kg weight loss; fortunately, the patient recovered completely. Thus the question arises whether such failures may be prevented. In addition, the need for uninterrupted vigilance in haemodialysis monitoring is stressed.
Cliniques Universitaires St. Luc, Service de Néphrologie, Bruxelles, Belgium.
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D000368:Aged; D004868:Equipment Failure; D006440:Hemofiltration / Q000009:adverse effects* / Q000295:instrumentation; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008991:Monitoring, Physiologic; D006435:Renal Dialysis / Q000009:adverse effects* / Q000295:instrumentation