Air embolism during renal dialysis is extremely rare because of the safeguards built into the apparatus and procedures currently used. This case is attributable to improper techniques used with venous access outside the monitored system.On completion of dialysis and disconnect from the machine and its safeguards, this patient had leg cramps. This common postdialysis complaint is routinely treated with intravenous saline from a fresh bag hung outside the machine for this purpose. Unfortunately, a previously used bag had not been replaced and soon ran empty after being connected to the patient's venous access. It was replaced hurriedly with a new bag without first bleeding the system of air.The patient collapsed, was transported to a hospital, and died 72 hours later without regaining consciousness. The diagnosis was confirmed by radiological and pathological examinations.The various mechanisms and pathways of venous to material transit are discussed.
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