Hemolysis associated with hydrogen peroxide at a pediatric dialysis center

Patients receiving hemodialysis therapy risk exposure to disinfectants used to reduce bacterial burdens in hemodialysis equipment and to reprocess hemodialyzers. From April 29 through May 9, 1988, 3 patients undergoing hemodialysis treatments at a single center were exposed to dialysis fluid that was inadvertently contaminated with hydrogen peroxide (HP). All patients showed a significant decline in blood hemoglobin level and required packed red blood cell transfusions during the 11-day exposure to HP. Contamination of dialysis fluid may have been due to the inadequate rinsing of HP from the water treatment system (WTS) following its disinfection on April 27-28, 1988. The failure to check water at point-of-use stations with a sensitive enough test kit after the disinfection for HP permitted patient exposure to contaminated dialysis fluid. To prevent similar occurrences, we recommend that after each disinfection (or other modifications of the WTS), the WTS be adequately rinsed to remove potentially toxic chemicals. Dialysis center personnel need to be aware of the potential effects that each modification or disinfection of the WTS may have on the product water used.