NEPHRETECT

Description of Event or Problem

PT WAS PREPARED FOR DIALYSIS AND AT THE ONSET OF DIALYSIS EXPERIENCED A REACTION, AND DIALYSIS WAS DISCONTINUED. TYPICAL SYMPTOMS OF REBOUND SYNDROME OCCURRED WITH A DROP IN BLOOD PRESSURE, DIZZINESS, AND PT LAPSED INTO A SEMI-CONSCIOUS STATE. BENADRYL WAS ADMINISTERED AND WITHIN 4-5 MINUTES, SYMPTOMS HAD SUBSIDED, BUT PT WAS ADMITTED INTO HOSP FOR OBSERVATION. NO FURTHER DEVELOPMENTS OCCURRED. IN DISCUSSING THE INCIDENT WITH THE CHIEF TECHNICIAN IT WAS BELIEVED THAT THE RINSING PROCEDURE WAS NOT FULLY FOLLOWED. CHIEF TECHNICIAN TESTED THE LOT TO DETERMINE ITS EFFICACY AND IT PROVED TO BE WITHIN SPECS. CO WILL TEST SEVERAL AMPULES FROM THE EFFECTED LOT AND SUBMIT THE RESULTS.