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Film: Showing the Redsense alarm reacting to a dislodged venous needle. Note that the only alarm you hear is Redsense.

Hemodialysis is a form of renal therapy so common that over 1.8 million lives depends on it worldwide.(ref 1) Quite understandably, patients believe that hemodialysis equipment offers a high level of safety and that in the event of venous needle dislodgement; the machine will stop pumping blood and sound an alarm.(ref 2) Most likely, it won't.

The typical venous needle dislodgement incident

An elderly man arrives at his dialysis unit for a scheduled treatment. His vital signs are normal. His needles are taped securely according to unit policy, treatment begins and his blood pressure is recorded to be normal on two occasions. A little later a nurse attending to another patient notices blood dripping on the floor beneath the mans chair. His venous needle is partially dislodged, the blood is mostly absorbed by his clothing and the chair, no alarm has sounded; he is unconscious. Blood pressure is unobtainable although a carotid pulse is present. A Hematocrit indicates 50% blood loss. Resuscitation is unsuccessful.

The manufacturers technician evaluated the machine and no faults were found. The unit was small and open plan; patients were constantly visible to the staff. Read more about this and other cases.(ref 2)

Bleeding

Significant, or even fatal, blood loss can easily occur when a venous needle becomes dislodged. It doesnt take long. This can happen when the patient turns over or if the needle gets caught without someone noticing.(ref 2) Fortunately, the vast majority of bleeding incidents are resolved quickly and efficiently by dialysis professionals who are only too aware of the risks involved. But while the chances of losing the patient may be small, waking up in a pool of blood is traumatic experience.(ref 3) In the US alone, 2 patiens are seriously injured every day (ref 12) and 2 patients die every week due to venous needle dislodgement.(ref 13) It is feared that the true death in the US is 3 to 4 times higher.(ref 2)

No one is immune to the risk of venous needle dislodgement, it can happen at any time.(ref 14) 200 needles come out during dialysis every day.(ref 15) The use of redsense blood detecting device may help to prevent the disaster for all involved when a venous needle dislodgement occurs and will provide much needed security.(ref 16)

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