Kes P, Veidlich D
Department of Nephrology and Dialysis, University Hospital Sestre Milosrdnice, Zagreb, Croatia.
Blood Purif. 1996;14(1):42-4. doi: 10.1159/000170240.
Undetected excessive ultrafiltration (UF) occurred in 2 patients on maintenance haemodialysis (HD) using a Gambro AK-10 monitor and Ergo 120 A-G blood lines. In spite of alarms present on the monitor, the dialysis staff was not alerted to the faulty condition. Through investigation of the HD 'set-up' at the time of the incidents it was found that a partial obstruction (kinking) had occurred in the extracorporeal blood circuit where the flexible tubing joined the venous chamber. This created a very high positive pressure within the dialyzer compartment and excessive UF, 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.
两名接受维持性血液透析（HD）的患者使用金宝AK - 10监测仪和Ergo 120 A - G血路管时发生了未被检测到的过度超滤（UF）情况。尽管监测仪发出了警报，但透析工作人员并未收到故障状况的提示。通过对事件发生时血液透析“设置”的调查发现，在体外血液回路中，柔性 tubing 与静脉腔连接的部位发生了部分阻塞（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。
