In September 1987, patients at an outpatient dialysis center were exposed to chloramine contaminated dialysate when the carbon filter in a recently modified water treatment system failed. Forty-one patients required transfusion to treat the resultant hemolytic anemia.
Full Answer
Why are patients exposed to toxic chemicals during dialysis treatment?
The reasons for patients being exposed to such toxic chemicals were water treatment failures at the drinking water treatment plant or dialysis center, incompatible dialysis solutions and distribution equipment/materials, and inadequate rinsing of dialysis systems after disinfection or newly installed dialysis systems.
What are the sources of contamination in dialysis machines?
The external surfaces of dialysis machines and components are also likely sources for contamination.
How vulnerable are dialysis patients to contaminants in water?
Hemodialysis patients are vulnerable to contaminants in the water used to prepare concentrate and dialysis fluid or in water used for reprocessing dialyzers (see "Reuse of dialyzers", section on 'Reprocessing techniques' ). This vulnerability is due to the following: ● Hemodialysis patients are exposed to extremely large volumes of water.
What causes infections among hemodialysis patients?
We review factors contributing to infections among hemodialysis patients and epidemiology of common infections and outbreaks, including bloodstream infections, vascular access infections, and infections caused by bloodborne pathogens.
What is the most common adverse event in patients receiving hemodialysis?
The most frequent adverse events related to vascular access for hemodialysis are bleeding, double lumen catheter secretion, inadequate blood flow, and infection or signs of vascular access infection.
Does hemodialysis increase risk of infection?
Patients who undergo dialysis treatment have an increased risk for getting an infection. Hemodialysis patients are at a high risk for infection because the process of hemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream.
What is the most common infectious complication in hemodialysis patients?
CAUSES OF BACTEREMIA These data also indicated that blood access infection is the most common cause of infection in hemodialysis patients.
What was the likely source of infection at the dialysis center?
Person to person transmission of pathogens is the most frequent route of transmission of infection in the dialysis unit. This contact transmission occurs most frequently when staff members do not follow infection prevention precautions and procedures.
What are the risk factors associated with the use of hemodialysis?
RisksLow blood pressure (hypotension). A drop in blood pressure is a common side effect of hemodialysis. ... Muscle cramps. Although the cause is not clear, muscle cramps during hemodialysis are common. ... Itching. ... Sleep problems. ... Anemia. ... Bone diseases. ... High blood pressure (hypertension). ... Fluid overload.More items...•
What was the likely sources of infection at the dialysis center quizlet?
Sources of infections include contaminated water, equipment, environmental surfaces, and infected patients.
What is the most common infectious complication in hemodialysis patients quizlet?
Hemodialysis Vascular Access Device (HVAD) Infections. The vascular access connection is the Achilles heel of dialysis. Complications of the vascular access are frequent and costly to the patient's health and to society. Thrombosis and infection are the most frequent causes of vascular access failure.
What germ causes the most common infections in hemodialysis patients?
Staphylococcus aureus is the most common microorganism implicated in vascular-access-related bloodstream infections (27.7–50.0%), followed by coagulase-negative staphylococci. As the leading pathogen causing bloodstream infection among patients on hemodialysis, S.
What is dialysis patient infection?
Septicemia is the leading cause of mortality attributed to infections in dialysis patients, and vascular access infections account for the majority of the cases. Risk factors for septicemia include anemia, vascular access being a catheter or AVG, hypoalbuminemia, dialyzer reuse and previous history of bacteremia.
How can you prevent infection and related problems in dialysis unit?
Appropriate exit site skin cleansing with chlorhexidine plus alcohol, routine performance of catheter hub disinfection (“scrub the hub”), and applying antimicrobial ointment or chlorhexidine-impregnated dressing to the catheter exit site are essential steps in infection prevention (1).
How do dialysis units prevent infection?
What patients can do:Clean your fistula site with soap and water before every dialysis treatment.Clean your hands with with soap and water or waterless alcohol-based sanitizer before you start your dialysis session and after you leave.More items...
How can you reduce the risk of infection for dialysis patients?
To reduce access-associated infections, centres should aim to increase the number of patients starting haemodialysis with arteriovenous fistulae, so limiting the use of central venous access catheters.
What is dialysis water?
For the purpose of discussion in this topic, the term "dialysis water" refers to water that has completed the process of decontamination in preparation for hemodialysis and the term "dialysis fluid" refers to dialysate, which is dialysis water mixed with electrolytes and a buffer as per the hemodialysis prescription.
How much water should I drink a week on hemodialysis?
Healthy individuals seldom have a weekly water intake of more than 14 liters (ie, 2 L/day). However, a typical hemodialysis prescription (thrice weekly for four hours per session with a dialysate flow rate of 800 mL/min) exposes the patient to more than 500 liters of water per week across the semi-permeable membrane of the hemodialyzer. ...
What is a novel bioassay?
Glorieux G, Schepers E, Schindler R, et al. A novel bio-assay increases the detection yield of microbiological impurity of dialysis fluid, in comparison to the LAL-test. Nephrol Dial Transplant 2009; 24:548.
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Is drinking water a regulatory requirement?
Drinking water is not always in compliance with these regulatory requirements [ 4-6 ]. As an example, in the municipal drinking water of several large cities in the United States, changes in water treatment practices and aging water distribution systems have resulted in levels of lead that were more than twice the Environmental Protection Agency action level [ 7 ]. Regulatory noncompliance is not limited to chemical contaminants, but can also occur for pathogens including bacteria, viruses, and parasites [ 8 ].
Is water used for dialysis safe?
Because of this substantially higher exposure to contaminants in water, additional treatment of water used for preparation of dialysis fluid is required. This topic discusses contaminants that may be present in drinking water, the safe levels of those contaminants in water used for hemodialysis, and the clinical risks to hemodialysis patients ...
When was hemodialysis first used?
When hemodialysis was introduced as a treatment for acute renal failure patients around 1945 (20), the importance of water and dialysate quality with regard to chemicals and microorganisms was not well recognized (21). This was in part because, until the 1960s, the procedure itself was not widespread and patients received a limited number of treatments. Even after hemodialysis became a mainstream therapy following the development of the Scribner shunt permanent vascular access in 1960, water quality was only factored in by controlling temperature and conductivity on the untreated source waters used for dialysis (21). This may have been a reflection of geography, as Ward pointed out, because in the beginning, the epicenter for hemodialysis was in the northwestern U.S. at the University of Washington in Seattle where the water quality is comparatively better than in other regions (21). Additionally, drinking water quality was not standardized until 1974 when the Safe Drinking Water Act (SDWA) was enacted.
What is the goal of hemodialysis water?
Once water enters a hemodialysis center, the goal is to achieve high quality and safe hemodialysis water and dialysate. Water treatment, system design, and distribution material choices are contributing factors. Dialysis water treatment should remove chemical and microbial contaminants to below established allowable limits and is characterized by two phases: (i) pretreatment, where constituents are removed from the feed water to protect the downstream treatment components and (ii) water treatment, which is the process of physically removing and/or chemically inactivating remaining chemical and/or microbial contaminants. Details regarding water treatment options and typical designs have already been given (8,14,15), but are briefly described here. Pretreatment includes the following: a blend valve – i.e., temperature controller to aid in efficient treatment downstream; multimedia depth filtration – composed of sand and/or coal, where the goal is to remove solids; granular activated carbon (GAC) filter(s) – absorb(s) organic matter that influences taste, odor, color, toxicity, and mutagenicity; softener – reduces the presence of cations (Ca2+, Mg2+, Sr2+, Fe2+, and Mn2+), which is measured as the ‘hardness of water’ and is commonly expressed as the concentration (mg/l) of CaCO3(16); and a prefilter – removes remaining particles (e.g., particulates and fine particles released from the GAC filters) prior to treatment. Water treatment includes reverse osmosis (RO) with/without deionization (DI) tanks, followed by these optional components: storage tank, ultraviolet (UV) irradiator, and ultrafilter/endotoxin-retentive filter (always used after storage tank, UV irradiator, or DI tank). RO is capable of excluding metal ions, aqueous salts, and molecules from the treated water. Ultrafiltration and endotoxin-retentive filters can be included after the deionizer, immediately after the storage tank, and/or before delivery to the dialyzer (depending on the design of the system) (13) to remove bacteria and endotoxin by using a positively charged filter surface and size exclusion.
What is the recommended endotoxin level for dialysis?
Conventional dialysis requires the endotoxin concentration in the dialysis water and dialysate to be <2 EU/ml with an action level of 1 EU/ml (Table 2) (5,6). However, the 2011 AAMI recommendations lowered the acceptable endotoxin concentration to <0.25 EU/ml in dialysis water and <0.5 EU/ml in the dialysate (8). Ultrapure dialysis requires the endotoxin concentration in the dialysate to be <0.03 EU/ml (no action level; Table 2) (2,8). The standard method for measuring endotoxin concentrations is the Limulus amoebocyte lysate (LAL) test. While two LAL approaches (kinetic and gel-clot assay) are approved in the Final Rule (5,6), the 2011 recommendations mention six different testing techniques (8).
How many people are on dialysis?
Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical. The Association for the Advancement of Medical Instrumentation has published both standards and recommended practices that address both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients, as shown by the continued episodic nature of outbreaks since the 1960s causing at least 592 cases and 16 deaths in the U.S. The importance of the dialysis water distribution system, current standards and recommendations, acceptable monitoring methods, a review of chemical, bacterial, and endotoxin outbreaks, and infection control programs are discussed.
What is validation of dialysis system?
Validation of a dialysis system is vital for establishing that the system can both provide the necessary water quality and whether the disinfection processes are sufficient at keeping the microbial contaminants below the maximum allowable limits.
What substratum is used in hemodialysis?
While the AAMI table offers a general list of materials, PVC (Type 1, Schedule 40 or 80) and SS (316L) are the two most used in hemodialysis systems. PVC is the more common substratum used due to availability and cost; however, an evaluation showed that purified water, chemical disinfection, and water flow ‘wore’ the material down over time (14 years) to create a surface that supported bacterial growth (18). In addition, the connections within a system must be welded or joined properly, so as to not create any rough edges where bacteria can proliferate; and proper angles are recommended to allow for an even flow (19).
When was the current CMS rule published?
The current CMS rules were published in 2008 (5) and are based upon recommendations made in 2004 by the Association for the Advancement of Medical Instrumentation (AAMI) (6). While the 2008 CMS regulations are directed at maintenance of hemodialysis facilities and are the minimum standards for water for dialysis and dialysate quality, the 2009 and 2011 updated recommendations by AAMI are more stringent and are voluntary (7,8). All of these guidelines and recommendations focus on the quality management of dialysis treatment, of which water or dialysate are the main topic.
When was chloramine contaminated dialysate?
In September 1987, patients at an outpatient dialysis center were exposed to chloramine contaminated dialysate when the carbon filter in a recently modified water treatment system failed. Forty-one patients required transfusion to treat the resultant hemolytic anemia. Epidemiologic investigation dem …
How long after chloramine exposure does dialysis increase?
Epidemiologic investigation demonstrated that the mortality rate among dialysis center patients increased during the 5 months after chloramine exposure when compared with the 12 months before chloramine exposure, but no deaths could be attributed to the exposure.
Is chloramine a disinfectant?
Chloramine is commonly used as a disinfectant in municipal water supplies, and has previously been reported to cause hemolytic anemia in patients undergoing dialysis.
What is the rationale for water treatment in hemodialysis?
For the rationale for water treatment in hemodialysis: “ Water Systems in Health-Care Facilities” in the Guidelines for Environmental Infection Control in Health-Care Facilities.
Why design and engineer water systems in dialysis settings?
Whenever practical, design and engineer water systems in dialysis settings to avoid incorporating joints, dead-end pipes, and unused branches and taps that can harbor bacteria.
How much water is used for hemodialysis?
During an average week of hemodialysis, a patient can be exposed to 300-600 liters of water, providing multiple opportunities for potential patient exposure to waterborne pathogens. Adverse patient outcomes including outbreaks associated with water exposure in dialysis settings have resulted from patient exposure to water via a variety of pathways; including improper formulation of dialysate with water containing high levels of chemical or biological contaminants, contamination of injectable medications with tap water, and reprocessing of dialyzers with contaminated water. For the health and safety of hemodialysis patients, it is vital to ensure the water used to perform dialysis is safe and clean.
Does reverse osmosis remove bacteria?
Yes, if the water treatment components in use are sufficient to remove or destroy bacteria, Reverse Osmosis (RO) will protect the product water from having microbial contamination. Deionization (DI) unit does not remove or destroy bacteria, so if DI is being used as the main water treatment (rather than RO), you will need a submicron or endotoxin/ultrafilter downstream of the DI unit. If an ultraviolet (UV) irradiator is used, the filter should be located after the UV irradiator. Close monitoring of the resistivity of the product water will be needed to detect any decrease in quality. Also consider weekly microbial assessment of the product water during the BWA.
What causes hemolysis during hemodialysis?
hemolysis during hemodialysis can occur as a result of dialyzing fluid that is heated to
What to do if hemolysis is suspected in a patient undergoing dialysis?
if hemolysis is suspected in a patient undergoing dialysis it is important to. stop the blood pump and treat patient symptoms, sample dialysate for ph and conductivity, check patients blood. if a patient has s/s of hemolysis do not. reinfuse blood, then clamp the blood lines.
Why do cells swell when they take water?
the dialysate concentration is to low, causing the cells to swell and burst as they take on water in an attempt to equalize their concentration of electrolytes with that in solution
What happens when one of the blood alarms is activated?
when one of the blood alarms is activated, the blood pump stops, there is an audio and visual alarm and the venous line clamp closes. Alarms that would cause this to occure are. arterial pressure, air detector, blood leack, venous pressure. all of the following affect solute clearance.
What are the symptoms of aluminum toxicity?
aluminum toxicity is a complication resulting from the use of. unpurified water , amphogel. signs and symptoms a patient may experience after an air emblism are. chest pain dyspnea, coughing cyanosis. cherry pop colored blood, hypotension, chest pain and a drop in hemoglobin/hematocrit are sighns of. hemolysis.
Why do you reposition a needle and adjust the blood flow downward?
reposition the needle and adjust the blood flow downward because of excess negative pressure on the arterial portion of the circuit
What is hemostasis dependent on?
hemostasis depends on. the ability of normal blood vessels to contract and retract when injured, the ability of platelets to form plugs in the injured blood vessels the presence of plasma coagulation factors the stability of the blood clot. a nonsteril aqueous solution that is similar to normal levels of electrolytes.
Why do you need to disinfect all pipes in a dialysis machine?
Disinfection must involve all the pipes in the distribution system of either water or dialysate solution and connectors to the dialysis machine to prevent the development of biofilm, a layer of polymeric organic matrix in which bacteria and fungi can grow.
How is dialysis infused?
Dialysate is infused through an abdominal catheter, and after a period of so-called “dwell time,” waste solution is drained from the abdomen.
What is the osmolality of dialysate?
Dialysate solution is almost an isotonic solution, with the usual osmolality of approximately 300 ± 20 milliosmoles per liter (mOsm/L). To ensure patient safety and prevent red blood cell destruction by hemolysis or crenation, the osmolality of dialysate must be close to the osmolality of plasma. The osmolality of plasma is 280 ± 20 mOsm/L. Dialysate solution commonly contains six (6) electrolytes: sodium (Na + ), potassium (K + ), calcium (Ca 2+ ), magnesium (Mg 2+ ), chloride (Cl – ), and bicarbonate ( ). A seventh component, the nonelectrolyte glucose or dextrose, is invariably present in the dialysate. The dialysate concentration of glucose is commonly between 100 and 200 mg/dL. Freshly prepared dialysate solution circulates continuously to the dialyzer in the extracorporeal circuit. After making a single pass through the dialyzer, the effluent dialysate goes to the drain.
What is the fluid delivery system?
The fluid delivery system is commonly called “the machine.” The fluid delivery system prepares dialysate , a body temperature electrolyte solution. The dialysate flows through the dialysate compartment of the dialyzer where dialysis occurs. A blood pump circulates the patient's blood through the extracorporeal circulation to the blood compartment of the dialyzer and back to the patient. The two major categories to monitor are the dialysate circuit and blood circuit.
What are the disadvantages of dialysate calcium?
The main disadvantage of high dialysate calcium concentration is hypercalcemia. Calcium-based phosphate binders, used preferentially over aluminum-containing antacids and oral or intravenous 1,25-dihydroxyvitamin D 3, are presently used in the management of hyperphosphatemia and to prevent uncontrolled secondary hyperparathyroidism. 68–70 High dialysate calcium concentration can limit the effectiveness of this therapy by inducing hypercalcemia. To obviate hypercalcemia , lower dialysate calcium concentrations (2.5 mEq/L) have been combined with high doses of oral calcium-containing phosphate binders and vitamin D sterols to control hyperphosphatemia 71 and secondary hyperparathyroidism. 72 Mild hypotension was the only major adverse effect associated with such dialysate calcium concentrations. 66,71 Thus, a dialysate calcium concentration of 2.5 to 2.7 mEq/L is recommended for hemodynamically stable patients, particularly for those prone to hypercalcemia during treatment with vitamin D and calcium salts.
What is the calcium level of dialysate?
Because dialysate calcium equilibrates with the diffusible (ionized) fraction of plasma calcium, a dialysate calcium concentration of 2.5 mEq/L is equivalent to a serum calcium level of 10 mg/dL. High dialysate calcium (3.5 mEq/L) or low dialysate calcium (<2.5 mEq/L) has certain risks and advantages.
Is dialysate sodium constant?
The dialysate sodium concentration is normally kept constant throughout the dialysis treatment. The variable sodium option allows dynamic changes of the dialysate sodium concentration during the treatment (sodium profiling). Although high-grade evidence is lacking, patients with hemodynamic instability may benefit from sodium profiling in which the initial sodium concentration is kept high and then slowly reduced by a degree similar to the initial sodium rise. Otherwise, sodium profiling usually results in a sodium load to the patient in the absence of equivalent reductions in dialysate sodium concentrations that may result in thirst and consequent increased interdialytic weight gain.