91. CRRT Scales Inspect scale for foreign object Replace effluent bag Bag is specified Warning (CAUTION) : Effluent bag full Bag is empty or supported Bag is specified Warning (CAUTION) : Bag container empty Change the effluent bag or modify “Bag Volume” Hang appropriate bag Allow bag to hang freely Hanging effluent bag does not match set “Allowed effluent volume” No bag on scale or bag is partially supported Warning (CAUTION) : Effluent bag incorrect Inspect scale component and remedy, then close properly Specific scale identified Warning (CAUTION) : Scale open
92. CRRT Scales Inspect bag/line for patency View history for flow volume May cause unsafe fluid balance errors Early notice of clamped bag or line immediately after a bag change Advisory : Clamped bag
109. Return Blood START RETURN activates blood pump only when pressed. When blood returned, press CONTINUE.
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115. Gambro is here to assist you 24 hours a day 7 days a week: 1-800-525-2623
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Editor's Notes
In this module, I will walk you through setting up the Prismaflex machine for therapy, which we will practice during the skills workshop. Most importantly, I will discuss how the Prismaflex machine balances fluid, as this is critical to your successful patient management.
This is the first screen to appear in Setup mode, assuming the power was turned off normally after the previous treatment was completed and the Treatment Complete screen was displayed when the power was turned off. If the power was not turned off at the Treatment Complete screen, or if power was lost, a query screen will appear asking if you wish to continue the procedure or restart. Refer to the Prismaflex Operator’s Manual. The softkeys are explained in order to choose the appropriate option. The THERAPY INFO softkey provides information on the therapy possibilities such as SCUF, CVVH, CVVHD, or CVVHDF. You can view this during the hands-on practice. Pressing CONTINUE allows the operator to move on to the next screen, which is CHOOSE PATIENT.
The CHOOSE PATIENT screen provides the following options: <read slide on NEW PATIENT and SAME PATIENT>. You can see that you do have other options available on this screen, e.g. entering custom mode, going to Therapy Info, or viewing the history from the last treatment. At this time, you must decide if you are setting up for a new patient or the same patient you have been treating (e.g. a new CRRT setup).
This screen asks you to enter a patient ID and a patient weight. While the machine doesn’t need this information to treat the patient, entry of this data provides some important benefits to you. By entering the patient’s weight, the system calculates and displays the delivered treatment dose based on the total effluent flow rates in ml/hr/kg body weight. Comparison to the prescribed dose allows you to monitor how well you are achieving the physician Rx. Additionally, entering a unique patient ID allows the unit to identify the patient on treatment. This capability is especially useful for hospitals that do electronic charting.
This screen allows you to select the therapy your physician has prescribed. The Prismaflex System will activate only the pumps used for each therapy. Therefore, if you wish to change therapy mid-treatment, you will have to end treatment and start a new one. One way to eliminate this limitation is to choose CVVHDF, regardless of the therapy ordered. This will activate all pumps and prime all lines during Setup. Simply turn unused flow rates to zero during treatment. For example, if CVVHD is ordered, you would setup in CVVHDF mode to prime all lines in the Prismaflex disposable set and activate all pumps. However, since replacement solution is not used during CVVHD therapy, you would simply set the replacement flow rate for zero. If the physician decides to change to CVVHDF mid-treatment, you can add the prescribed replacement solution to the replacement scale and reset the flow rate per the physician’s order. Recognize that there may be flow rate limitations based on the therapy originally chosen if you change therapies during the treatment.
Once the therapy mode is chosen, the Prismaflex provides you with a set of instructions for the set-up and priming. At this point, you need to have your prescribed Prismaflex CRRT hemofilter set opened and ready to attach to the machine. It is best to follow the step-by-step instructions on the screen to ensure you don’t miss a step. Pressing the softkey beside the instruction will change the schematics appropriately to give you a visual aid for the procedure.
It is important to follow the positioning of the effluent line into the BLD as shown to allow adequate air removal during the priming procedure and prevent false blood leak alarms during the treatment.
Once you have completed all the instructions on the screen and press the LOAD softkey, the machine will automatically load the cassette into the pumps. At the same time, the bar code reader identifies the hemofilter set using the label on the back of the cassette. Inspect the set for proper loading, which means: - the cassette is loaded securely - the pump segments are loaded properly in the pumps - the lines are positioned properly in the pinch valves Some precautions are listed on the screen to prevent errors in identifying the filter set and ensure smooth priming, including inspecting the line for kinks, or closed clamps which may have resulted from the loading procedure or from packaging of the set.
Once the machine has successfully loaded the set, the system will display the identity of the hemofilter set and provide its operating limits. Verify that the filter set loaded is the one prescribed by the physician. Errors in identifying the set may occur if there are kinks or improper loading of the set, or the wrong filter set is loaded. Press UNLOAD and correct the conditions. Note the operating limits of the selected hemofilter set and ensure that the patient’s flow rate prescription is capable with the filter placed on the machine. Then press CONTINUE to proceed to the next set of instructions.
The system will give you information on how much volume is recommended for proper priming of the filter set and which syringe should be used for the syringe pump. In order to avoid missing a step, especially for beginners, press each key and follow the instructions displayed and visualize the step involved. The first step requires that you connect to a priming solution. Gambro’s recommended priming solution is heparinized normal saline (5000u/1L). After these steps are completed, you may connect your solution or blood warmer.
Each mode has different setup and solutions requirements. Review this slide and the requirements of CVVHDF.
Each mode has different setup and solutions requirements. Review this slide and the requirements of CVVHD.
Each mode has different setup and solutions requirements. Review this slide and the requirements of CVVH.
Each mode has different setup and solutions requirements. Review this slide and the requirements for SCUF.
The system provides you the option to use the syringe or to not use the syringe. If using the syringe pump, proceed by pressing INSTALL SYRINGE softkey to access the instructions to calibrate the syringe being used. Choosing NO SYRINGE disables the use of this pump for this treatment. (Note: It is possible to install the syringe with normal saline so you have the option to use an anticoagulant later on in the treatment, if prescribed.)
If using the syringe pump, the system will ask you to confirm proper loading of the syringe into the pump holder.
Although there were no instructions to close any of the clamps, the last step on this page is to ensure that all clamps are open, and the connections are secure. This is also a good time to check for kinks on the lines, and to make sure that seals in the bags are broken. Pressing PRIME takes you to the next step .
As soon as priming starts, check that all solutions flow freely to avoid priming errors. Observe for leaks from the set <read slide>. It is possible to interrupt the procedure at any time by pressing the STOP softkey to stop priming and correct a situation before it becomes a problem. This screen also informs you how much time is left for the priming to be completed <continue to read slide>. When you press the PRIME softkey, the Prismaflex system will perform a 7-minute prime cycle. The goal of PRIME is to remove air and residual sterilant from the blood and fluid lines, as well as the filter. Removing air is very important to prevent clotting during treatment. It is important to not disturb the set during the initial part of PRIME by tapping on the hemofilter, pinching lines, etc. This may create micro-bubbles and foam. Wait until 2 or less minutes remain in PRIME to gently tap the header and pressure pods to remove any remaining air bubbles. Never clamp the blood/fluid lines during PRIME to remove residual air.
If more priming is necessary to remove air from the blood/fluid circuit, press REPRIME or MANUAL PRIME. MANUAL PRIME activates only the blood pump while the softkey is being pressed. When you stop pressing the softkey, the blood pump will stop. Remember to first check if more priming solution is required (which is usually the case), and if the effluent bag needs to be replaced.
REPRIME automatically repeats the priming procedure for all the lines (including dialysate, replacement, PBP). REPRIME may be necessary to remove unusually large amounts of air in the filter set. This will require a new bag of priming solution. Check the effluent bag, if full replace effluent bag is needed.
The Prime Test is the initial test that the machine does to ensure proper working conditions throughout the treatment. (A shorter version is done during the treatment.) This procedures takes approximately 7 minutes to complete. This page displays the component being tested and the system will announce immediately after if it fails.
DO NOT Press CONTINUE unless you are ready to start treatment and connect the patient. Otherwise, stay on this page so that the option to reprime, manual prime, or adjust the deaeration chamber is still accessible. Testing of the remote control is done only if applicable.
After the &quot;Prime Test Passed” screen is displayed, The Excess Patient Fluid Loss or Gain Limit is displayed. This limit controls the amount of unintended fluid loss or gain allowed in the patient in any 3 hours (180 minutes) of treatment. Enter the prescribed limit and/or follow your facility’s protocol for setting an appropriate limit. Patient’s size, clinical condition, and hemodynamic stability are key factors to consider. For High-flow set, the pre-set value of the Excess Patient Fluid Loss or Gain limit is 330 ml with a settable range between 100 to 400 ml within 3 hours time period. For a Low-flow set, the pre-set value is130 ml with a settable range of 100 to 200 ml within 3 hours BE AWARE! The limit cannot be changed once you CONFIRM and leave this screen. Consult your manager if you have questions Does anyone have any questions on loading and priming the Prismaflex set?
In this module, we’ll review how to start the patient’s treatment since the system is primed and ready to go.
Before you connect the patient, you want to make sure the patient’s prescription is entered into the Prismaflex screen. This screen allows you to program the parameters for the treatment and is available anytime during the treatment from the STATUS screen. Select the parameter you want to adjust at the bottom of the screen, ensure it is highlighted on the screen, and then modify the value using the up/down arrows at the side of the screen. The blood flow is automatically selected as soon as this screen appears. Enter the prescribed blood flow rate. And proceed to the next appropriate flow rate to set based on the therapy you have chosen to deliver.
As you know, Replacement is available in CVVH and CVVHDF modes. Note that the right hand side of the screen gives you important information regarding the allowable rates, etc. Change the value as prescribed by the physician by using the up/down arrows. The volume infused by the replacement pump is automatically removed by the system, therefore should not be added to the fluid intake calculation.
Once your replacement flow rate is entered select the PRE or POST softkey to select the dilution method prescribed by the M.D. Note that the calculated delivered dose, based on the set patient weight, is displayed on this screen as “Rate per Pt. kg: xx ml/hr/kg”. Dr. Ronco recommends a dose of 35 ml/kg of body weight/hr.
The Dialysate softkey is available in CVVH and CVVHDF. The Dialysate scale may be used as a second replacement fluid pump during CVVH therapy. The maximum flow rate includes the sum of the replacement and PBP flow rates up to a maximum of 8L/hr.
The goal of fluid management in CRRT according to the ANNA standard of clinical practice is to achieve and maintain fluid volume balance within the planned or anticipated goals. The maximum patient fluid removal for the Prismaflex in all modes of therapies is 2L/hr. The rate is prescribed by the physician. The nurse should assess the patient’s hemodynamic parameters and the patient’s response to the prescribed fluid loss prescription. This Total Patient Fluid Removal rate is the sum of the hourly net fluid removal prescribed by the physician and Non-Prismaflex intake (such as IV, TPN, etc.) minus Non-Prismaflex output (urine, emesis, etc.). See the equation displayed on the screen to review patient fluid removal calculation.
The pre-blood pump (PBP) may be u sed to infuse solutions before blood pump such as for additional pre-dilution replacement or anticoagulation. PBP flow rate CAN NOT exceed blood flow rate Blood pump compensates for additional PBP infusion by speeding up to maintain set blood flow rate at the physician prescribed blood flow rate. Note : PBP Rate in ml/hr while BFR in ml/min
The PBP can be activated in all modes of therapy, including SCUF. PBP pumps sterile solution into the blood pathway very close to the access connection. This may be used to pump anticoagulant solutions, as a direct pre-filter infusion of other solutions or as an optional pre-dilution replacement solution such as PrismaSol. Solution infused by this pump is automatically removed by the effluent pump therefore should not be included in the calculation as patient intake. Because the pump is in the circuit before the blood pump, the blood pump must compensate for the PBP flow rate (for example: if the blood flow rate is set at 200ml/min and the PBP is set at 1000ml/hr or 16ml/min, the blood pump will deliver 216ml/min (200 ml/min blood + 16 ml/min PBP solution). The display will still show QB at 200ml/min.)
-Syringe pump flow rates are also set from the SETTING FLOW RATES screen. Access the Syringe Pump Settings by selecting SYRINGE PUMP softkey in the upper right corner of the screen. Choose CONTINUOUS or BOLUS delivery (intermittent delivery of a bolus volume during treatment) -Immediate BOLUS delivery only available after start of treatment. -Press CONFIRM to enter values -Note: Volume infused must be added as Intake
After all prescribed flow rates have been entered, press the ENTER softkey to confirm the prescription.
The next screen displayed allows you to review the set flow rates one more time. If you wish to change one of the flow rates, this can be done by pressing FLOW RATES. If the flow rates are correct, press CONTINUE to connect the patient.
Press the soft button next to each instruction on the screen to visualize diagram of each step. Read the screen . Remember to close all clamps that you will be disconnecting to avoid spilling fluid. Connect the access line to the red port of the patient’s catheter and the return line to the blue port of the catheter. The effluent line is disconnected from the Y-set which was connected to the priming bag and connected to the effluent bag. Once connections are completed, remember to Open the clamps on the Catheter and all lines . Close clamps on lines that are not used for the treatment such as PBP, or replacement solutions. After doing the final check on all the connections and lines, press START to start the treatment.
Now that the patient is connected, we will discuss management of the treatment.
The Status screen appears as soon as you press the START soft key and enter the RUN Mode. The Status screen is the main operating screen while the treatment is underway. Describe the different sections of the screen so the user knows where to look for each value displayed. Here you can see the mode of therapy being delivered according to the pumps that are activated, the flow rate settings at a glance, the therapy dose delivered if patient weight was entered, the pressure conditions in the set, and pressure graphs to be able to assess clotting trends. The therapy dose delivered is calculated according to the patient weight and set flow rates.
An initial assessment of the vascular access is important at this point by observing the access and return pressures. After a few seconds of starting, as long as the flows in the vascular access are sufficient, the pressures stabilizes and the pressure limits are established. A red square appears and places the current pressures at mid-point. When the pressure changes and goes beyond the red squares, the machine will notify you and create an visual and audible alarm. A continuous increase in the access, return or effluent pressures usually signifies clamp/s that were not opened. We will discuss how to trouble shoot these alarms in the next modules. The Status Screen also provides a graphical display of the filter pressure drop and the TMP as these are important values to trend for filter clotting. The softkeys on the bottom of the display are used to navigate away from the Status Screen . We will discuss all the functions keys in the next slide.
Pressing STOP to stop all the pumps. This comes in handy when you notice a situation that needs to be corrected right away (i.e. leaking connections, etc.). After STOP has been pressed, press RESUME to restart treatment. An advisory alarm (BLOOD FLOW STOPPED) occurs when the blood pump is stopped for more than 60 seconds. This screen allows the user to CHANGE SET when the advisory alarm occurs after 72 hours of filter use or 780L of blood or fluid has been processed. This is also the screen to access when you want to end the treatment.
During the treatment, it is possible to make changes to the existing flow rates, just by pressing the FLOW RATE soft key. Simply press the flow rate to be changed and modify using the up/down arrows to reach the desired value. Press ENTER key once after all the changes are made. The option to change the settings for the syringe is also available.
CHANGE BAGS: This soft key is pressed when the user needs to change the bags before the advisory alarm. (For example: Solution Prescription Changed.) It is important to physically open and close the appropriate scale one at a time to ensure accurate fluid reporting.
This screen allows you to view cumulative fluid balance for up to 24 hours at a time. The screen automatically displays the last completed I/O period. The RUN TIME increases as treatment progresses. You should review the cumulative fluid balance and confirm the right volumes at least hourly throughout the therapy to ensure accurate fluid management. For example: if the replacement flow rate is set at 1000ml/hr, the replacement volume infused in half hour should show 500ml. The effluent pump pulls dialysate, replacement solution, PBP, and patient fluid from the hemofilter through the effluent port and into the effluent bag. The effluent pump volume equals the sum of the patient fluid removal, dialysate flow, replacement and PBP volume. The sum of the replacement, dialysate, PBP and patient fluid removal should equal the volume of fluid in the effluent bag. A discrepancy would indicate a problem with the patency of the corresponding lines. Additional information such as the blood/fluid volume processed is the total Liters of blood or fluid pumped through the filter set being used. This will give you an idea of how long it will take before the filter needs to changed. This screen also provides access to the EVENTS and Fluid and Pressure Graph. Pressing the STATUS softkey returns to the main screen. You can also choose to view a different time period by pressing CHANGE PERIOD.
To view a different time period, press CHANGE START TIME and CHANGE END TIME to change the time period by pressing the arrow keys. It is important to press the END TIME softkey twice to change the actual period displayed.
Certain Events that may occur during setup and the delivery of a treatment are stored and displayed in the three Events screens. PrismaFlex stores the date, hour, and minute the events occur, as well a description of the event. Up to five thousand events can be stored. (Color-coded according to type of event) Events are displayed in chronological order, starting with the most recent. Arrow keys on the Events screens allow the operator to scroll up or down this list. When the operator presses the EVENTS softkey from the History screen, all events are displayed. If desired, the operator can then view only the alarm-related events or only the events related to flow rates and syringe pump setting.
Pressing the SYSTEM TOOLS softkey bring you to this screen. This page provides access to instructions for important procedures such as; PRESSURE PODS (For pod repositioning) ADJUST CHAMBER MODIFY SETTINGS CLEAN SCREEN SELF-TEST NORMALIZE BLD (Blood Leak Detector)
The deaeration chamber is a clever mechanism that was devised to accommodate a high blood flow rate and large amounts of solution (up to 10L/hr). The high blood flow rates and large amounts of fluid moving through the circuit create turbulence and may cause air formation. The blood enters at the bottom of the deaeration chamber where it circles around the funnel inside the chamber. At the top of the chamber replacement solution enters and creates a layer over the blood. The layer of solution places a barrier between the air and blood. As the blood moves around the funnel, the air is pushed up into the replacement solution where the air is absorbed and removed via the return monitor line, semi-automatically. It is recommended that the user delivers at least 200cc/hour of replacement solution post-filter to avoid clot formation in the deaeration chamber. The layer of solution decreases clot formation and increases circuit life. This is not a requirement, but only a suggestion to assist our customers in using the system more effectively.
See the Operator’s Manual to manage a situation in which fluid enters the machine through the deaeration chamber monitor line.
The next module of Prismaflex System training provides an overview of the basic alarm conditions and machine management of those alarms.
In order to discuss the alarms, you first need to know the safety feature components of the Prismaflex starting from the alarm lights and display panel, the pressure monitoring system, the blood leak detector, the air bubble detector and return line clamp/blood sensor, the scales, syringe pump and the bar code reader.
The Prismaflex Alarm System The Prismaflex control unit continually monitors itself and the Prismaflex set for proper functioning during operation. If an abnormal situation occurs, the operator is notified via a red or yellow status light and an audible alarm. In addition, an Alarm screen with instructions on how to respond to the alarm appears on the display. WARNING occurs when a patient hazard exists. This requires prompt operator intervention (for example, air bubbles in the return line or extreme positive pressure in the return line). MALFUNCTION occurs when a system hazard exists. This requires prompt operator intervention (for example, return clamp failure or periodic self-test failure). CAUTION occurs if a condition exists that the proper action is to suspend treatment, but it is safe to continue blood and anticoagulant flow (for example, when dialysate or replacement bag is empty or the effluent bag is full). ADVISORY occurs if a condition exists that the operator should be aware of, but the patient is not at immediate risk (for example, preventive maintenance is due). The patient’s treatment will continue. All alarms are prioritized. This means that if multiple problems exist, only the highest-priority alarm screen is displayed. Clearing the highest-priority alarm causes the next highest priority alarm screen to be displayed, and so on. As each alarm appears on the display, the operator follows the instructions on the screen in order to respond to the alarm.
The three commandments in PrismaFlex troubleshooting are: Read the screen – the Prismaflex machine gives you a detailed explanation of the alarm situations and the procedure to resolve the situations. Follow the Steps. When responding to any alarm, carefully follow the instructions you are given on the displayed Alarm screen. The Alarm screens give on-line instructions for responding to most alarm situations. Under certain circumstances, however, the alarm system cannot give all the detailed instructions. Detailed instructions are given in the Operator’s Manual.
The Operator is always notified of abnormal situations and needed actions by alarm screens. When the alarm situation is remedied, the alarm screen disappears. Some alarms can also be overridden.
Each alarm situation will display a set of softkeys needed to remedy the alarms, such as the following: <read screen> Whenever an alarm occurs, the EXAMINE ALARMS softkey appears and the name of the alarm is stored in a pending (active) alarms list. Until the alarm is cleared, the EXAMINE ALARMS softkey remains displayed and the alarm name remains in the pending alarms list. Overridden alarms are considered active alarms. OVERRIDE: This Softkey overides an and alarm for 60 seconds. When the condition is remedied the alarm will clear. Some softkeys that appear in the operating screens may also appear on the alarms screen. These softkeys function the same way .
Pressure alarm system guards patient safety during treatment. Therefore, it would be helpful to understand what type of pressures are being monitored by the System and what these pressures mean. The Prismaflex System measures pressures at four points in the extracorporeal circuit, namely: access , return, filter, and effluent. We will go through each one of these points in the following slides.
Access pod measures the extracorporeal pressure as the blood “exits” the vascular access. The access pressure is measured to prevent excessive suction by the blood pump. This pressure is measured before the blood pump and is typically negative between -50 to -150 mmHg , depending on blood flow rate, and blood source. If blood entering the Prismaflex circuit is from another blood source like an arteriovenous fistula or ECMO, the access pressure will tend to be more positive. The Prismaflex system can operate with access pressures between –250 to +350mmHg.
At the start of treatment, if the access pressure is between –10 to +10mmHg, an advisory alarm occurs so that the user can confirm if the access monitoring range should be negative or positive for the rest of the treatment. Ensure secure connection to blood source. This happens when the blood flow rate is too low for the type of blood source, such as an AVF or a large bore catheter. Always confirm a negative range unless the blood source is from an external blood device . It patient condition allows, increase blood flow rate until the access pressure goes more negative than –10mmHg to avoid an ‘Access Disconnection’ alarm.
To avoid accidentally pressing the positive range, the system will require a re-confirmation from the user.
Return pressure monitor measures the extracorporeal pressure as the blood re-enters the vascular access. This measurement prevents return of blood to the vascular access against excessive resistance. The return pressure is measured after the blood pump and is typically positive between +50 to +150 mmHg. The Prismaflex can operate between +50mmHg to +350mmHg range.
Errors in pressure readings from the return line monitor may occur as a result of wet fluid barrier. These may present as Code 20 during the prime self-test, TMP alarms during patient treatment, etc. To avoid wetting the fluid barrier, monitor the level of fluid in the deaeration chamber during your hourly checks, adjust level of fluid in the deaeration chamber if necessary and avoid unnecessary adjusting of chamber level during set up.
Filter pod measures the extracorporeal pressure as the blood enters the hemofilter. Filter pressure is measured after the blood pump and is typically positive between +100 to +250 mmHg. Since it is measured before the hemofilter, it is the most positive (highest) pressure in the Prismaflex Set . The Prismaflex System can operate between -50mmHg to +450mmHg range.
Effluent pod measures the pressure in the effluent line as the ultrafiltrate exits the hemofilter. Depending on the therapy chosen and the ultrafiltration rate, the effluent pressure can be positive or negative between +50 to -150 mmHg. The Primaflex System can operate between -350mmHg to +350mmHg range.
The Prismaflex software uses monitored pressure values to calculate vital filter pressure conditions, such as Trans-membrane Pressure (TMP) and the Filter Pressure Drop as displayed on the Status screen during the operation of the system . These pressure calculations indicate conditions within the filter and provide notification that clotting or plugging of the membrane pores is beginning, or has already occurred in the filter and the Prismaflex set must be changed.
Trans-membrane Pressure, or TMP, is defined as the pressure exerted on the filter membrane during the operation of the system. It reflects the pressure difference between the fluid and blood compartments of the filter.
The TMP is calculated and automatically recorded when: Entering Run mode ( when pumps have attained proper speed and blood flow through the Set is stabilized) Blood flow rate is changed Patient fluid removal rate is changed Replacement solution rate is changed During a patient treatment, permeability of the membrane decreases due to protein coating on the blood side of the membrane. This causes the TMP to increase. The amount of increase above the initial TMP value contributes to trigger the clotting alarm.
Filter pressure drop is the change of pressure from blood entering and leaving the filter. It is a calculated value to determine pressure conditions in the hollow fibers of the filter. The initial value for the FPD is calculated and automatically recorded upon entering the RUN mode when the blood flow rate is stabilized and every time the blood flow rate is changed. The amount of increase above the initial filter pressure drop contributes to the trigger of clotting alarms.
Access Pressure alarms may occur with the patient changing positions or temporary kinking of line. This alarm may self-clear if pressure returns to normal. This alarm is triggered when the access pressure exceeds –250 mmHg. When alarm occurs, read the screen for possible causes and resolve obvious reasons. The most common is due to vascular access issues. If this is so, refer to the hospital policy and follow the hospital procedure. The hospital policy may include: Flush the catheter to move it away from the vessel wall Reposition the patient to increase internal pressure around the catheter tips. Switch the bloodlines so the access bloodline is attached to the blue port of the catheter and the return bloodline is attached to the red port of the catheter. This might work if there is fibrin coating the outside of the catheter. Observe the catheter size. The catheter could be too small for the patient and desired blood flow rate. The catheter might need to be replaced if unable to maintain a blood flow rate. The blood flow rate may need to be decreased until a new catheter is placed or while you call the physician. However, if the operator is unable to maintain a blood flow rate of at least 100 ml/min in an adult patient, END TREATMENT and return the patient’s blood before the system clots.
There could be other issues causing problems with flow through the vascular access or Access bloodline. Some institutions place stopcocks inline with the Prismaflex bloodlines. The stopcock may not have the same inter-lumen size as the Prismaflex bloodline, which will cause excessively negative access pressure. The operator should also ensure the bloodlines and catheter are unclamped and not kinked.
The alarm “Return Pressure Extremely Positive” Occurs when return pressure exceeds +350 mmHg. The alarm indicates an obstruction somewhere in the blood return pathway, whether it be in the Return line of the Prismaflex set or in the return lumen of the vascular catheter. When alarm occurs, read the screen for possible causes and resolve obvious reasons. The most common is due to vascular access issues. If this is so, refer to the hospital policy and follow the hospital procedure. The hospital policy may include: Flush the catheter to move it away from the vessel wall Reposition the patient to increase internal pressure around the catheter tips. Switch the bloodlines so the access bloodline is attached to the blue port of the catheter and the return bloodline is attached to the red port of the catheter. This might work if there is fibrin coating the outside of the catheter. Observe the catheter size. The catheter could be too small for the patient and desired blood flow rate. The catheter might need to be replaced if unable to maintain a blood flow rate. The blood flow rate may need to be decreased until a new catheter is placed or while you call the physician. However, if the operator is unable to maintain a blood flow rate of at least 100 ml/min in an adult patient, END TREATMENT and return the patient’s blood before the system clots.
Other issues may cause problems with flow through the vascular access or Return bloodline. Some institutions place stopcocks inline with the Prismaflex bloodlines for infusing things into the patient. The stopcock may not have the same inter-lumen size as the Prismaflex bloodline, which will cause excessively negative access pressure. Additionally, infusing anything into the Return side of the Prismaflex circuit will impact the return pressure, as it increases pressure. The operator should also ensure the bloodlines and catheter are unclamped and not kinked. Note: If the patient has high intra-thoracic or intra-abdominal pressure, such as ascites, it could increase the Return pressure. In this case, consider relocation of catheter to different site or decreasing the blood flow rate until situation has improved. Remember, if the blood flow rate cannot be maintained at 100 ml/min or higher, your circuit will clot more frequently.
Access disconnection alarm occurs when the access pressure falls below –10 to +10mmHg. This happens when the access line is disconnected from the catheter, etc. (read slide).
Return disconnection could occur for the same reasons as access disconnection. These are (read slide)….
Review Slide with conditions for Advisory: Cannot detect access or return.
The “filter extremely positive” may occur for the following reasons. (Demonstrate alarm).
Review slide
Review Slide
A true blood leak alarm is due to blood escaping into the effluent when hollow fibers break. This may occur if the filter is dropped on the floor or if one taps the filter headers using a heavy instrument. Dropping the filter or tapping the headers with a heavy instrument could cause the polyurethane potting compound to crack. However, in the acute setting, blood leak alarms are usually caused by the patient’s condition or disease process such as in liver failure, or rhabdomyolysis in which the presence of bilirubin or myoglobin is released into the effluent causing changes in the light transmission in the BLD .
Review Slide Note: If the Effluent line is repositioned or removed/reinserted in the detector, the detector must be reset before continuing with treatment: Pressing Systems tools Pressing NORM BLD BLD signal value must be greater than or equal to 38,000 for normalization to be allowed.
Review slide
Send Effluent sample to STAT lab as blood sample. The lab must run an RBC count via quantitative method. The result should be zero. Consider utilizing a peritoneal cell count lab test so when talking to lab about testing effluent they will understand and have a comparative lab procedure. DO NOT use any kind of dip stick, such as Hemastix, to test effluent. These test strips test for the presence of Heme. The Heme unit is a component of Myoglobin and Bilirubin and may give a false positive result. Also assure the lab will not to run the effluent sample as a urine sample, but as a blood sample. Urine samples do not offer the same quantitative analysis as blood samples.
The Ultrasonic Air Bubble Detector: Consists of two pieces of electric ultrasonic transducers (a transmitter and a receiver ), located on the right lower front panel of the Prismaflex system. The detector monitors a small section of the return line tubing before blood gets returned back to the patient. When an air bubble passes through the ‘detection area’, some of the ultrasound is absorbed by the air bubble resulting in a reduction in the level of sound detected by the receiver. If a large bubble passes through the detector, or many bubbles pass through during a specified time the air in blood alarm occurs which shuts down the blood pump and the return line clamp. A Warning alarm occurs. The two infrared patient/blood sensors are also located in the air bubble detector housing to detect if blood is in the tubing. A tubing detection switch physically moves down when tubing is installed. The air bubble detector works with the other components of the return pressure monitor such as DEAERATION CHAMBER, and the monitor line. The Deaeration Chamber manages air that enters the circuit. Bottom to top blood flow in the set provides a unique conveyance path that works like a vortex to propel all air out of the blood. The Monitor Line that Connects the deaeration chamber to an internal pressure sensor monitors the return pressure and enables removal of air from the chamber, if needed. A fluid barrier at the end of the line protects the interior of the control unit from accidental blood/fluid entry. Tightening the connections is part of the usual setup and treatment management duties. Post -filter replacement solution is added into the deaeration chamber on top of the blood. Using a minimum 200-500 ml/hr of post filter replacement will prevent air/blood interface. This is recommended to minimize clotting/foaming into deaeration chamber.
Review Slide
Another potential cause: A blood warmer can generate air bubbles which collect in the return line pressure pod and may induce air in blood alarm over time. It is not recommended to use a heater on replacement solution line (Operators Manual : precautions section)
Other alarms that may occur during Setup, Run, End Treatment rely on the different safety components. The bar code reader ensures that the correct filter set was installed for the chosen therapy mode. If the wrong set is loaded, the system will find the filter to be incompatible with the therapy. It is possible to re-select the loaded filter, or unload and change the filter set to the prescribed. It is also possible that the filter is not positioned properly in the cassette holder or the dialysate line may have been inadvertently closed.
SYRINGE EMPTY/CLAMPED alarm will occur when: Syringe pump not loaded correctly Syringe not connected properly Follow the instructions on the screen to resolve the condition. Remember that if the syringe function is disabled, it is not possible to use this for the rest of the treatment.
180 ml/min x 60 minutes = 10800ml/hour x 72 = 777600 ml is 777.6 L
Alarm related to conditions on the scale may occur during Setup or Treatment: Review table and alarm conditions.
Continue review of table.
The Incorrect Weight Change Alarm occurs as the PrismaFlex System’s fluid control unit detects Patient fluid removal variance from the prescribed set fluid removal rate. The control unit balances fluid through continuous feedback among the scales, software, and pumps. The software sends messages to the communication unit to display fluid variance directly on screen. Four scales independently monitor the weight of the fluid bags. A Caution alarm will notify the operator that a fluid variance occurred in the calculations of the fluid balance within the System.
During the setup mode, after PRIME TEST PASSED, the PrismaFlex will ask the operator to choose an excess patient fluid loss or gain limit for the treatment. It is important to set this limit according to the volume that your patient will tolerate if inadvertently gained or lost in the event of patient fluid imbalance. This limit varies for every individual patient and should be determined according to their size, clinical condition, and hemodynamic stability. The Excess Patient Fluid Loss or Gain Limit or threshold must be prescribed by the physician/clinician. For example, a small patient or hemodynamically unstable patient may require a lower limit (130 ml over 3 hours) while a more hemodynamically stable, larger patient can tolerate a higher limit (400 ml over 3 hours). Blood flow, patient fluid removal and solution flow rates are part of the prescription requirement to perform the treatment. The Excess Patient Fluid Loss or Gain limit is a safety tool for patient care management . Consult with a prescribing physician to determine the appropriate limit for your patient, or follow the facility's protocol for setting an appropriate limit and resolution to the fluid error. The alarm limit ranges from 100 to 400 ml within a 3 hours period. The machine will default to a set value according to the type of filter used. (review slide table) This limit can only be changed during setup. If a new setting is required, the operator must return to Set Up starting and choose NEW PATIENT.
Important: A small amount of variance from the set pt fluid removal rate can normally be seen due to any of the following events: Alarm condition that stops the fluid pumps. Treatment is stopped , then resumed later on A Change bag interruption due to an end infusion alarm Voluntary pressing of the CHANGE BAGS soft key to change a bag. RUN TIME (the cumulative time that the blood was effectively treated with all pumps running) is directly affected by the events listed. The Run Time is always displayed on the History screen
Incorrect Weight Change Detected alarm occurs when the weight of one or more scales does not change according to the set fluid flow rates. Here is a list of causes that may trigger this alarm ( read slide ).
Review this slide and following slides.
How a fluid flow obstruction may result into a patient fluid Gain or Loss? Patient fluid Loss may occur when the flow of the replacement, PBP, or dialysate solutions is obstructed. Excess fluid may be pulled from the patient through the blood compartment of the filter.
How a fluid flow obstruction may result into a patient fluid Gain or Loss? Patient fluid Gain: If the cause of incorrect weight change is obstructed flow from a clamped effluent bag, then excess fluid may be infused back to the patient.
This advisory alarm provides early notification of a flow problem that could potentially cause serious fluid errors if unresolved. At this stage, fluid balance is not yet compromised, especially if corrected immediately. This is an advisory alarm which means that all fluid pumps are operational.
The Prismaflex software expects weight to change in accordance with the flow rates set by the user. The Incorrect Weight Change alarm occurs when a +/- 40 ml deviation is detected, due to a clamped or kinked line. This will trigger an IWC detected alarm. The machine will alert the operator with a CAUTION alarm that corresponds to the affected scale. This can happen if flow is obstructed from or into one of the solution or effluent bags during treatment and CONTINUE is pressed without solving the issue. This screen also provides current information on the volume of unexpected patient fluid lost or gained in the 3 hour cumulative run time. For example: this screen shows that the patient has lost 83ml in excess of the set fluid removal rate . The next line shows the limit, previously set by the user, of 130ml of allowable fluid variance for patient fluid loss or gain with any 3 hour time period. The machine will then instruct the user to CHANGE SET or END TREATMENTT. Finally, it also provides instructions on how to troubleshoot the condition.
Review Slide and Following slides.
When the amount of patient fluid removal variance exceeds the allowable pre-set limit within the 3 hour period, the treatment is suspended and instructions to end treatment appear. Remember that the fluid pumps have stopped, but the blood pump is still running. Important: You cannot CANCEL this operation, the operator must end the treatment. Gather your supplies to return blood to the patient or discontinue treatment without blood return. When you are ready, press STOP to stop the blood pump.
Does anyone have any questions about the Prismaflex system?
This is the last section of the setup and operation of the Prismaflex System.
Standby Mode is automatically entered when pressing the STOP key on the Status screen. By pressing the appropriate key, you are able to make the following selections: RESUME : To restart pumps, resume treatment CHANGE SET : To change the set and then resume treatment . Instructions are given to return the blood (optional), disconnect the patient, unload the set and load a new set. RECIRC: To return blood to the patient; temporarily disconnect and recirculate saline through the blood lines. When ready, reprime the set; reconnect patient and resume treatment. END TREATMENT: To terminate the treatment . Instructions are given to return the blood (optional), disconnect the patient, unload the set and terminate the treatment. Choosing this option puts the machine in the End mode.
When RETURN BLOOD is pressed, the flow rate requires a setting that allows the operator to control the rate especially when the rate and volume of blood is critical, as in pediatric patients. To continue, follow step-by-step procedure with illustration. Procedure: Access line is disconnected from the patient and connected to a saline bag using a spike. In the case of recirculation the spike is connected to a Y-set to which the access and return lines are connected to form the circle.
Recirculate mode is used to temporarily disconnect the patient for a procedure, test, etc. Recirculation requires per screen instructions: Blood to be returned to the patient, Patient disconnection, and Circulation of Normal Saline through the set. Before the patient is reconnected, a shortened priming procedure is done. After returning the blood, this screen appears to enter the blood flow rate rate. Only the blood pump can be activated during this process. NOTE: The volume of NS recirculated during this time, is added to the total blood/fluid processed through the filter . When a total volume of 780 liters has been processed, the Advisory: Time to Change Set alarm occurs. F or example, recirculation at 100 ml/min for two hours would add 12 liters to the total volume processed. The syringe pump, if activated during the treatment, is able to give immediate bolus only. The total recirculation time depends on the facilities policies.
28 It is possible to end the treatment with or without returning the blood to the patient by choosing RETURN BLOOD or simply disconnecting. End treatment includes the following procedure: disconnecting the patient, unloading and removing the filter set, and disconnecting the bags .
This screen prepares the set for unloading from the machine. Unloading disables the air detection alarm. Note: To save the left-over solution for the next filter set, ensure the sterility of the solutions during the disconnect from the filter set.
Confirm Unload gives the user another chance to ensure the safety of the patient before proceeding. Make sure that the patient is disconnected from the machine and that all clamps are closed before unloading.
This screen provides the option to view the treatment history and to start a new treatment. On the History screen, it is possible to download the information into a data card. New treatment is a quick way to use the machine for another patient.
One last note: Gambro is available 24 hours a day for assistance with any operating problems. Please feel free to use this number any time and any day of the week.
