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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 1  |  Page : 107-110
Successful recovery from iatrogenic severe hypernatremia and severe metabolic acidosis resulting from accidental use of inappropriate bicarbonate concentrate for hemodialysis treatment


Department of Anaesthesia and Critical Care, Institute of Kidney Diseases and Research Center and Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India

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Date of Web Publication8-Jan-2015
 

   Abstract 

Bicarbonate dialysis is the treatment modality of choice for correction of metabolic acidosis in chronic renal failure. However, improper selection of dialysate concentrate can result in life-threatening human errors. We report a case of iatrogenic severe hypernatremia (sodium 207 mEq/L) and severe metabolic acidosis (pH 6.65) that resulted due to accidental use of inappropriate bicarbonate concentrate for hemodialysis treatment. There was successful recovery in this patient with no neurological sequelae. To the best of our knowledge, this is the first case report in adults of severe hypernatremia along with severe metabolic acidosis due to error in the preparation of dialysis fluid.

How to cite this article:
Bhosale GP, Shah VR. Successful recovery from iatrogenic severe hypernatremia and severe metabolic acidosis resulting from accidental use of inappropriate bicarbonate concentrate for hemodialysis treatment. Saudi J Kidney Dis Transpl 2015;26:107-10

How to cite this URL:
Bhosale GP, Shah VR. Successful recovery from iatrogenic severe hypernatremia and severe metabolic acidosis resulting from accidental use of inappropriate bicarbonate concentrate for hemodialysis treatment. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 May 23];26:107-10. Available from: http://www.sjkdt.org/text.asp?2015/26/1/107/148754

   Introduction Top


Hemodialysis (HD) using bicarbonate concentrate (bicarbonate dialysis) is the treatment modality of choice for correction of metabolic acidosis in chronic renal failure. However, improper selection of dialysate concentrate can result in life-threatening conditions. We report a case of iatrogenic severe hypernatremia with severe metabolic acidosis resulting from accidental use of inappropriate bicarbonate concentrate for HD treatment. Acute development of severe hypernatremia is rare, leading to major neurological complications or death. [1] However, this is a unique report of a patient who accidently developed hypernatremia and recovered fully without any subsequent neurological damage.


   Case Report Top


A 54-year-old man, a known case of hypertension since five years, was admitted to our tertiary care hospital with complaints of breathlessness, vomiting, fever, oliguria and generalized weakness for one week. On examination, he had a heart rate of 120 bpm, respiratory rate of 34/min, blood pressure of 150/88 mm Hg and temperature of 39°C. Ultrasound disclosed bilateral small contracted kidneys with loss of corticomedullary differentiation. Arterial blood gas (ABG) analysis showed pO2 of 90 mm Hg, pCO2 of 43 mm Hg, pH of 7.07, bicarbonate of 13 mmol/L, base deficit of 14 mmol/L, oxygen saturation of 89%, sodium of 150 mmol/L and chloride of 107 mmol/L. Urgent HD using bicarbonate bath was started through a temporary femoral catheter.

Two hours after starting HD, the patient had a generalized tonic-clonic seizure followed by confusion and agitation. Seizure activity was treated with intravenous diazepam. He had further decreased level of consciousness, bradycardia and hypertension (160/118 mm Hg) requiring treatment with nitroglycerin infusion.

The patient was intubated and started on mechanical ventilation. In view of increasing agitation, fentanyl and midazolam infusions were started. ABG analysis performed at this stage showed severe metabolic acidosis (pH 6.65, bicarbonate 3.5 mmol/L, base deficit 33.3 mmol/L), marked hypernatremia (207.5 mmol/L), hyperchloremia (168.8 mmol/L) and hyperkalemia (7.41/L). Incorrect preparation of dialysis fluid was suspected and then confirmed by analysis of dialysis fluid, which showed a very acidic pH (< 6.5) and very high concentration of electrolytes beyond the measurable range of the ABG machine.

The dialysis fluid is available in two parts. Part I is in a 10 L plastic container while part II is available in the powder form, which is mixed with 10 L of purified water [Table 1] and [Table 2]. In the dialysis machine, one volume of part I is diluted with 34 volumes of purified water and mixed with 1.83 volumes of reconstituted part II to provide a bicarbonate bath of 35 mmol/L and sodium of 136 mmol/L. Instead of using two different solutions, both solutions used in this case were of part I. High conductivity alarm in the dialysis machine had triggered but was ignored by the dialysis technician.
Table 1: Composition of bicarbonate dialysis fluid (part I). Available in 10 L plastic can. Each 1000 mL contains:

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Table 2: Composition of bicarbonate dialysis fluid (part II): Available in plastic pouch. Each pack contains

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After correcting the dialysis fluid, HD was restarted and the serum sodium was restored to 156 mmol/L after eight hours [Figure 1]. Dialysis was repeated the next day and sodium reached a normal level (138 mmol/L) after 48 hours. The hemodynamics and level of consciousness of the patient returned to normal within 24 hours without any focal neurological abnormalities. When the patient was awake and responding to verbal commands, he was extubated. Magnetic resonance imaging (MRI) of the brain was performed on the third day, and it showed normal findings. The patient was shifted to the ward on the fifth day. He did not have any clinical neurological sequelae from hypernatremia after three months of follow-up.
Figure 1: Serum sodium and chloride levels in the study patient.

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   Discussion Top


This is a very unusual case as our patient survived severe hypernatremia and acidosis without any neurological damage. There have been instances of acute metabolic acidosis resulting from accidental use of inappropriate bicarbonate concentrate for HD. [2],[3] There has been a case report from Spain of a 7-year-old girl who developed severe hypernatremia (Na 216 mmol/L) due to wrong reconstitution of dialysis solution. [4] However, this is the first case report in adults of severe hypernatremia along with severe metabolic acidosis due to error in the preparation of dialysis fluid.

In our case, because of similar appearance of part I and reconstituted part II solutions (both being 10 L, wrongly labeled), both containers used were of part I, leading to a very high concentration of acid and electrolytes. High conductivity alarm was ignored by the technician and an increasing amount of acid concentrate with high sodium content was delivered to the patient, leading to severe hypernatremia with severe metabolic acidosis.

It is important that the conductivity alarms should never be ignored and a rapid examination of the dialysis fluid should be performed in patients who unexpectedly deteriorate rather than improve with dialysis. Navarro et al [5] has studied a similar situation in vitro and concluded that during bicarbonate dialysis, an inappropriate acidic dialysate fluid could replace the normal dialysate fluid, still maintaining adequate range of conductivity and, therefore, no alarms are triggered. Many reports [2],[3],[5] have proposed online pH meters in addition to conductivity with alarm systems in the HD machines in order to averting such a problem.

Acute development of severe hypernatremia is rare, arising from a net water loss and/or hypertonic sodium gain. [1] While dehydration is the most common cause of water loss, etiological factors in hypertonic salt gain could be intravenous infusion of hypertonic saline, excessive salt ingestion or bicarbonate administration during cardiac arrest. Among patients with serum sodium level ≥160 mmol/L, the reported mortality rate is 70%, with children having better survival than adults. [1] Several neurological complications underlie the high mortality in severe hypernatremia, the most common being shrinkage of cerebral cells leading to intracranial vascular damage and hematomas, [6] and protective adaptive response in the form of severe brain edema. [7] In our case, MRI of the brain was performed 48 h after acute hypernatremia, and it was normal. There have been a few reports of adult patients who survived from severe hypernatremia (≥200 mmol/L) without subsequent neurological damage. [1],[8] Williams et al [9] have reported five patients on maintenance HD who developed acute hypernatremia (sodium levels from 158 mmol/L to 179 mmol/L) due to hypernatremic dialysate from a granular and less-soluble batch of sodium bicarbonate powder. With the exception of one patient who developed pulmonary edema, symptoms were minimal and, in each case, hypernatremia was corrected without residual complications.

We used HD to correct the high sodium concentration. Peritoneal dialysis or HD has been used previously to correct the hypernatremia. [10],[11] Such methods should be considered if sufficient natriuresis cannot be obtained with diuretics. [1]

This case underlines the importance of conductivity alarms during HD and rechecking of dialysis fluid for electrolytes and pH in a patient who deteriorates rather than improving after starting dialysis.

Conflict of interest: None

 
   References Top

1.
Albi A, Baudin F, Matmar M, Archambeau D, Ozier Y. Severe hypernatremia after hypertonic saline irrigation of hydatid cysts. Anesth Analg 2002;95:1806-8.  Back to cited text no. 1
    
2.
Cao Huu T, Jonon B, Chanliau J, Barre P, Kessler M. Error of dialysis concentrate: A cause of severe metabolic acidosis not detected by certain generators. Nephrologie 1990;11:91-4.  Back to cited text no. 2
    
3.
Golphinopoulos S, Oustabasidou N, Liakopoulos V, Kiropoulos T, Stefanidis I. Accidental acute metabolic acidosis due to inappropriate selection of bicarbonate concentrate. EDTNA ERCA J 2005;31:85-7.  Back to cited text no. 3
    
4.
Borrego Domínguez RR, Imaz Roncero A, López-Herce Cid J, Seriñá Ramírez C. Severe hypernatremia: Survival without neurologic sequelae. An Pediatr (Barc) 2003;58:376-80.  Back to cited text no. 4
    
5.
Navarro JF, Mora-Fernández C, Garcia J. Errors in the selection of dialysate concentrates cause severe metabolic acidosis during bicarbonate hemodialysis. Artif Organs 1997;21: 966-8.  Back to cited text no. 5
    
6.
Handy TC, Hanzlick R, Shields LB, Reichard R, Goudy S. Hypernatremia and subdural hematoma in the pediatric age group: Is there a causal relationship? J Forensic Sci 1999;44:1114-8.  Back to cited text no. 6
    
7.
Gullans SR, Verbalis JG. Control of brain volume during hyperosmolar and hypoosmolar conditions. Annu Rev Med 1993;44:289-301.  Back to cited text no. 7
    
8.
Park YJ, Kim YC, Kim MO, Ryu JH, Han SW, Kim HJ. Successful treatment in the patient with serum sodium level greater than 200 mEq/L. J Korean Med Sci 2000;15:701-3.  Back to cited text no. 8
    
9.
Williams DJ, Jugurnauth J, Harding K, Woolfson RG, Mansell MA. Acute hypernatraemia during bicarbonate-buffered haemodialysis. Nephrol Dial Transplant 1994;9:1170-3.  Back to cited text no. 9
    
10.
Moritz ML, del Rio M, Crooke GA, Singer LP. Acute peritoneal dialysis as both cause and treatment of hypernatremia in an infant. Pediatr Nephrol 2001;16:697-700.  Back to cited text no. 10
    
11.
Pazmiño PA, Pazmiño BP. Treatment of acute hypernatremia with hemodialysis. Am J Nephrol 1993;13:260-5.  Back to cited text no. 11
    

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Correspondence Address:
Dr. Guruprasad P Bhosale
Department of Anaesthesia and Critical Care, Institute of Kidney Diseases and Research Center and Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat
India
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DOI: 10.4103/1319-2442.148754

PMID: 25579726

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