Hemolysis due to inadvertent hemodialysis against distilled water: Perils of bedside dialysate preparation.
OBJECTIVE
To describe the physiologic consequences of dialysis against distilled water and to provide recommendations by which other institutions may avoid similar errors in dialysate preparation.


METHODS
Four cases of dialysis against distilled water are described, occurring at three teaching hospitals within a 2-yr period. In addition, an in vitro experiment of banked whole blood exposure to distilled water dialysate was performed.


METHODS
Because all four cases occurred within a critical care setting, intensive monitoring of clinical, biochemical, and hematologic abnormalities was possible.


RESULTS
Serum sodium decreased by an average of 22 mmol/L, followed by a decrease in hemoglobin averaging 32 g/L. Additional investigations and the in vitro experiment provided evidence that hemolysis occurred primarily via clearance of damaged erythrocytes within the patient's reticuloendothelial system. Physiologic derangements secondary to dialysis against distilled water likely contributed to a stroke suffered by one patient and the death of at least one other patient.


CONCLUSIONS
Accidental dialysis against distilled water is a potentially serious but preventable complication of bedside dialysate preparation.
Pendergrast
Jacob M
JM
Division of Transfusion Medicine, Department of Laboratory Medicine and Pathobiology, University of Toronto, University Health Network, Toronto, Canada.
Hladunewich
Michelle A
MA
Richardson
Robert M A
RM
D000328:Adult; D000368:Aged; D001639:Bicarbonates / Q000627:therapeutic use; D015314:Dialysis Solutions / Q000009:adverse effects*; D004339:Drug Compounding; D005260:Female; D006461:Hemolysis; D006801:Humans; D007010:Hyponatremia / Q000209:etiology; D008274:Magnesium / Q000627:therapeutic use; D008297:Male; D019300:Medical Errors; D006435:Renal Dialysis / Q000009:adverse effects*; D012965:Sodium Chloride / Q000627:therapeutic use
D001639:Bicarbonates; D015314:Dialysis Solutions; C483808:Normocarb; D012965:Sodium Chloride; D008274:Magnesium