Objective: To describe the physiologic consequences of dialysis against distilled water and to provide recommendations by which other institutions may avoid similar errors in dialysate preparation.
Data Source: Four cases of dialysis against distilled water are described, occurring at three teaching hospitals within a 2-yr period. In addition, an in vitro experiment of banked whole blood exposure to distilled water dialysate was performed.
Data Extraction: Because all four cases occurred within a critical care setting, intensive monitoring of clinical, biochemical, and hematologic abnormalities was possible.
Data Synthesis: Serum sodium decreased by an average of 22 mmol/L, followed by a decrease in hemoglobin averaging 32 g/L. Additional investigations and the in vitro experiment provided evidence that hemolysis occurred primarily via clearance of damaged erythrocytes within the patient's reticuloendothelial system. Physiologic derangements secondary to dialysis against distilled water likely contributed to a stroke suffered by one patient and the death of at least one other patient.
Conclusions: Accidental dialysis against distilled water is a potentially serious but preventable complication of bedside dialysate preparation.