• Boris I Medarov, Suneet Pahwa, Stephanie Reed, Richard Blinkhorn, Neha Rane, and Marc A Judson.
• 1Division of Pulmonary, Critical Care and Sleep Medicine, Albany Medical Center, Albany, NY. 2Manager, Dialysis Unit, Albany Medical Center, Albany, NY. 3Department of Medicine, Albany Medical Center, Albany, NY.
• Crit. Care Med. 2017 Feb 1; 45 (2): e232-e235.

ObjectiveTo evaluate the root cause of a series of methemoglobinemia cases in a medical ICU.ResultsWe report a sentinel case of methemoglobinemia that was associated with dialysis sessions using a portable dialysis unit in our hospital. This led to the identification of four additional patients who developed methemoglobinemia while undergoing portable dialysis. We determined that these episodes were caused by inadequate clearance of chloramine from the tap water used for portable dialysis. Introduction of larger capacity carbon filters into the portable dialysis systems resulted in no further cases of methemoglobinemia at our institution.ConclusionsClinicians should be aware of municipal tap water as a potential cause of methemoglobinemia and monitor for excessive levels of oxidants in dialysis water sources. The capacity of the hemodialysis equipment to clear chloramine can vary as a function of external factors. Using a reliable test method to identify chloramines in the water prior to entering the hemodialysis equipment is essential.

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