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.
Stragier
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Cliniques Universitaires St. Luc, Service de Néphrologie, Bruxelles, Belgium.
Maes
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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