During the 3rd shift on b-side of the op dialysis unit, 3 patients were finished and 5 remained.The 5 were halfway done with their treatment when their machines began alarming sporadically and patients began to complain of tingling in hands and face.Some experienced moderate hypotension.Treatment stopped and blood was returned.Renal panels and blood cultures were obtained.Patients were given novasource.After labs were resulted, the patients were moved to a side for one hour hemodialysis with a 3k bath.Symptoms resolved and patients were discharged.This patient's signs and symptoms were tingling to hands and face.She was in chair 18.2k bath.Units a and b are on different loops.Daily bicarb and acid added at 4:30am following routine process and usual staff.Ro water tested- normal.Storage tanks for bicarb checked after incident.No sludge seen.Conference call to fresenius (b)(6) 2017 to discuss incident and ask for assistance in determining possible cause.
|