Dear colleagues,
I would like to appeal again for clinical staff to share your experiences of hemolysis during dialysis sessions. Please remember this information will be treated sensitively and of course you can add your comments anonymously if required.
Franta Lopot, from the Czech Republic asked the following questions:
"I would like to discuss another aspect of the article - it seems that hemolysis manifested by an increasing pattern of the relative blood volume despite significant ultrafiltration. It is very interesting as it gives another dimension to continuous blood volume monitoring (CBVM). Another interesting aspect of the work was a common complaint of post-dialysis abdominal pains in those patients with hemolysis. I wonder whether there is any medical or biochemical association between hemolysis and those pains?"
To Frantas question, I have received the following from Liz Harman, one of the authors of the paper...
"We use blood volume monitoring on all of our patients every treatment, specifically Critline from Hemametrics. This allows us to more closely control the fluid removal from our patients and we have drastically reduced our cardiac events. When the hemolysis occurred the Critline volume showed an increase or became positive instead of negative as usual and the hematocrit decreased instead of increased as is usual with hemoconcentration as fluid is removed. In retrospect we understand now that the Critline showed us the release of fluid into the vascular space as the cells were being lysed and the accompanying increase in blood pressure and decrease in hematocrit as cells were destroyed all made sense. The instrument alerted us, but because we had never seen this before we did not interpret it correctly at the time of the events.
What we do now if we are even the least suspicious and see that the blood volume is increasing even though we have programmed a target into the machine, is a quick pink test. We draw a couple of cc's of blood into a serum separator tube and spin down. If the serum is pink we have hemolysis. Fortunately it has not happened again and we are very much more alert to our patients' symptoms. We are grateful that we have another instrument to help in the monitoring of our patients." I think it is to the authors credit that they have used the information gleaned incidents to improve clinical practice and further enhance patient safety.
Lizzi Lindley from the UK made the following observations: "There is a nice MSc project here for a renal technologist to look at the change in signal from a blood volume monitor if you progressively haemolyse the blood passing through the chamber in the lab.
I have seen apparent rapid increases in blood volume when there is a clot in the chamber; I guess this is because the clot has very different optical characteristics to free red cells. If the staff do not try to resolve the problem, the apparent BV change often drops in steps after the initial increase. This may be because the clot is breaking up or because it is dropping out of the path of the light beam.
Elisabeth Harman reported that the blood volume increased in these cases of dialysis induced hemolysis. I guess this is for the same reason. One thing that might be useful in the detective work is that when the staff restarted the BVM in case 2; the BV change was negative - suggesting the hemolysis was now a smaller effect than haemoconcentration. With hindsight, perhaps it is possible to restart the BVM with the UF off, to see if the haemolysis was ongoing.
For me, the lesson learned from the ANNA report is that when a blood volume monitoring system gives apparently funny data, we should take it seriously! A rising BV after the patient is established on dialysis is unusual. Staff need to look at the monitoring chamber and check there is no clotting inside it, and then look out for the symptoms described in the report. In the report, patients who experienced serious hemolysis had pruritis (itching), increasing BP, felt shivery then had a high temp, were slow to respond and flushed, had back pain, shortness of breath, nausea and abdominal pain."
Perhaps a JC member could explain these commonly observed symptoms that Franta and Lizzi have highlighted?
Of interest to JC members following this discussion, is a paper from Kidney International: Duffy R, Tomashek K, Spangenberg M, et al. 'Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets.' (Kidney Int 2000 Apr;57(4):1668 - 74). The abstract is available at www.ncbi.nlm.nih.gov/site...t=Citation
Thank you to all our contributors and as ever, I look forward to receiving your comments.
Best regards
Gareth Murcutt
EDTNA/ERCA Journal Club Manager
I would like to appeal again for clinical staff to share your experiences of hemolysis during dialysis sessions. Please remember this information will be treated sensitively and of course you can add your comments anonymously if required.
Franta Lopot, from the Czech Republic asked the following questions:
"I would like to discuss another aspect of the article - it seems that hemolysis manifested by an increasing pattern of the relative blood volume despite significant ultrafiltration. It is very interesting as it gives another dimension to continuous blood volume monitoring (CBVM). Another interesting aspect of the work was a common complaint of post-dialysis abdominal pains in those patients with hemolysis. I wonder whether there is any medical or biochemical association between hemolysis and those pains?"
To Frantas question, I have received the following from Liz Harman, one of the authors of the paper...
"We use blood volume monitoring on all of our patients every treatment, specifically Critline from Hemametrics. This allows us to more closely control the fluid removal from our patients and we have drastically reduced our cardiac events. When the hemolysis occurred the Critline volume showed an increase or became positive instead of negative as usual and the hematocrit decreased instead of increased as is usual with hemoconcentration as fluid is removed. In retrospect we understand now that the Critline showed us the release of fluid into the vascular space as the cells were being lysed and the accompanying increase in blood pressure and decrease in hematocrit as cells were destroyed all made sense. The instrument alerted us, but because we had never seen this before we did not interpret it correctly at the time of the events.
What we do now if we are even the least suspicious and see that the blood volume is increasing even though we have programmed a target into the machine, is a quick pink test. We draw a couple of cc's of blood into a serum separator tube and spin down. If the serum is pink we have hemolysis. Fortunately it has not happened again and we are very much more alert to our patients' symptoms. We are grateful that we have another instrument to help in the monitoring of our patients." I think it is to the authors credit that they have used the information gleaned incidents to improve clinical practice and further enhance patient safety.
Lizzi Lindley from the UK made the following observations: "There is a nice MSc project here for a renal technologist to look at the change in signal from a blood volume monitor if you progressively haemolyse the blood passing through the chamber in the lab.
I have seen apparent rapid increases in blood volume when there is a clot in the chamber; I guess this is because the clot has very different optical characteristics to free red cells. If the staff do not try to resolve the problem, the apparent BV change often drops in steps after the initial increase. This may be because the clot is breaking up or because it is dropping out of the path of the light beam.
Elisabeth Harman reported that the blood volume increased in these cases of dialysis induced hemolysis. I guess this is for the same reason. One thing that might be useful in the detective work is that when the staff restarted the BVM in case 2; the BV change was negative - suggesting the hemolysis was now a smaller effect than haemoconcentration. With hindsight, perhaps it is possible to restart the BVM with the UF off, to see if the haemolysis was ongoing.
For me, the lesson learned from the ANNA report is that when a blood volume monitoring system gives apparently funny data, we should take it seriously! A rising BV after the patient is established on dialysis is unusual. Staff need to look at the monitoring chamber and check there is no clotting inside it, and then look out for the symptoms described in the report. In the report, patients who experienced serious hemolysis had pruritis (itching), increasing BP, felt shivery then had a high temp, were slow to respond and flushed, had back pain, shortness of breath, nausea and abdominal pain."
Perhaps a JC member could explain these commonly observed symptoms that Franta and Lizzi have highlighted?
Of interest to JC members following this discussion, is a paper from Kidney International: Duffy R, Tomashek K, Spangenberg M, et al. 'Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets.' (Kidney Int 2000 Apr;57(4):1668 - 74). The abstract is available at www.ncbi.nlm.nih.gov/site...t=Citation
Thank you to all our contributors and as ever, I look forward to receiving your comments.
Best regards
Gareth Murcutt
EDTNA/ERCA Journal Club Manager
