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. A review of the literature demonstrates that while thermal hemolysis only occurs in temperatures of at least 47 degrees C, patients exposed to overheated dialysate at much lower temperatures may still be at risk for hyperthermia and heat stroke.