Background

Our technical director Bob Wilson recently had an article published in the Waterline, the journal of the Water Management Society. It was about the use of hydrogen peroxide for the disinfection of hospital water systems. It provides information on the serious consequences that can occur when hydrogen peroxide or indeed any oxidising chemical enters a Dialysis machine. It emphasises the importance of through risk assessment when disinfecting. I thought it was important to share.

Letter to the editor

Water supply to Hospital Dialysis Units
People have short memories.
The History

It is over 10 years since there was a fatality in Leicester General, caused by a silver stabilised hydrogen peroxide (SSHP) disinfectant entering the hospital’s dialysis units. This occurred because the main water system in the hospital was being disinfected with SSHP, and this water also supplied the dialysis unit. This is the third time when patients in a hospital dialysis unit have been affected by hydrogen peroxide. The first was in a new hospital in Israel where the dialysis unit had been pre- flushed with hydrogen peroxide prior to start up and the residual hydrogen peroxide had not been rinsed from the system – 9 young people became ill. The second was in Dumfries and Galloway Royal Infirmary, again following a disinfection using SSHP . 4 dialysis patients became very ill. This incident was fully investigated and a paper was produced which detailed the findings (Unexpected Cyanosis in a haemodialysis patient – did someone add hydrogen peroxide to the dialysis water ? NDT PLUS 2009 pages 158-160 Newbigging N. et al).

The Problem

The problem is that when hydrogen peroxide or any oxidising chemical enters a dialysis unit it reacts with the blood preventing the blood from taking up oxygen, and causing the patient to become very ill. This paper concludes “Dialysis Units that continue to receive at least some of their water from the hospital mains water tanks remain at risk”

From a hospital’s perspective this means that Dialysis units should have their water supply separated from the main hospital supply.

The Answer

From a water treatment perspective it means that a rigorous risk assessment should be conducted prior to carrying out a disinfection of a hospital water system to ensure that a dialysis unit is not included in the circuit being disinfected. I have come across a few articles/blogs recently that suggest that the Leicester General fatality could have been prevented if an encapsulate hydrogen peroxide or a peroxide stabilised with something other than silver ion had been used. This is dangerous! The problem is hydrogen peroxide, or any oxidising chemical, not silver. If you are using any hydrogen peroxide based chemical in a hospital water system please take the utmost care.

– Bob Wilson

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