Kes P, Veidlich D
Department of Nephrology and Dialysis, Sestre Milosrdnice University Hospital, Zagreb, Croatia.
Acta Med Croatica. 1996;50(2):107-10.
Undetected excessive ultrafiltration occurred in a patient on maintenance hemodialysis using a Gambro AK-10 monitor and Ergo 120 A-G blood lines. In spite of alarms present on the hemodialysis monitor, the dialysis staff were not alerted of the failure. The patient had nausea, vomiting, abdominal cramps and hypotension. The monitor was withdrawn from service and subjected to careful technical checks, but no failure could be detected. Thorough investigation of the hemodialysis 'set-up' at the time of the incident revealed a partial obstruction (kinking) to have occurred in the extracorporeal blood circuit where the flexible tubing joined the venous chamber. This had created a very high positive pressure within the dialyzer compartment and excessive ultrafiltration, which the blood circuit pressure monitoring transducer was unable to detect. To prevent kinking of the blood lines, dialysis staff and patients should be instructed to ensure that blood lines lie in smooth curves.
一名使用金宝AK - 10监测仪和Ergo 120 A - G血路管进行维持性血液透析的患者发生了未被检测到的过度超滤情况。尽管血液透析监测仪发出了警报，但透析工作人员并未收到故障提示。患者出现恶心、呕吐、腹部绞痛和低血压症状。该监测仪被停用并进行了仔细的技术检查，但未发现故障。对事件发生时血液透析“装置”的全面调查发现，在体外血液回路中，柔性 tubing 与静脉腔相连处发生了部分阻塞（扭结）。这在透析器隔室内产生了非常高的正压和过度超滤，而血液回路压力监测传感器无法检测到这种情况。为防止血路管扭结，应指导透析工作人员和患者确保血路管呈平滑曲线放置。
