Overheated dialysate: a case study and review.

Overheated dialysate has been reported as a cause of fatal hemolysis, both acute and chronic. However, published incidents are several decades old and only include cases where the dialysate was overheated above 47 degrees C or where the temperature was not reported This case study examines an incident where a faulty plumbing valve introduced hot water into a cold line used exclusively ror inpatient dialysis in an intensive care unit, causing the dialysate temperature to raise as high at 39.8 degrees C before the treatment was terminated early.