Top Tips: An Aquarius System PCRRT Workshop handbook 1 ... · Top Tips: An Aquarius System PCRRT Workshop handbook AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd. PM-0032-06/2015.

Top Tips: An Aquarius System PCRRT Workshop handbook

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd. PM-0032-06/2015. Copyright 2015. All rights reserved.

pCRRT Aquarius Top Tips Workshop

1. Practical Workshop

The workshop presents a primed Aquarius in recirculation mode. Each group will be supported to

practically connect and run a brief therapy simulation. 10 minute discussion on Troubleshooting -

common alarms (high and low priority), teaching appropriate observation skills and responses.




Alarm Cause Options for error removal Action

Low Access Pressure (Access pressure below the

lower alarm limit of 0 to -250mmHg)

Blood flow is too low/blood pump is off. Assess vascular catheter for occlusions/clots. Access line is kinked/clamped. Tubing set is kinked close to access or pre-filter pressure sensors.

Check blood flow rate. Consider increasing the blood pump speed Check patient access. Reposition the patient. Access is against the vessel wall. Reposition the catheter and/or line. Swap the lumens over. Consider aspirating the lumens. Consider pulling the catheter back. Consider a new catheter. Review anti-coagulation. Rotate the blood pump ¼ anti-clockwise. Remove the kink/unclamp the line Check access line, including

access and pre-filter sensors, for

kinks or occlusions.

Prepare to end the therapy.

Restart the blood pump.




High Access Pressure (Access pressure exceeeds

alarm limit of

between -50 and +200mmHg)

Consider anticoagulant and replacement fluid review. Check patient access. Reposition the patient. Access is against the vessel wall. Reposition the catheter and/or line. Consider aspirating or swapping the lumens. Consider pulling the catheter back. Consider a new catheter. Review anti-coagulation. Remove the kink/unclamp the line





Low return pressure (Return pressure is below the

lower alarm limit of 20 to 200mmHg)

Blood flow rate is too low. The blood pump has stopped. Return line is disconnected.

Consider increasing the blood pump speed. Restart the blood pump. Check vascular access connections.


High Return Pressure (Return pressure exceeds the

upper alarm limit of 120 to 300mmHg)

Return line is kinked or clamped. Return line is occluded or clotted. Drip chamber is clotting. Faulty return pressure transducer.

Remove the kink/unclamp the line. Reposition the line. Consider swapping the lumens Consider anticoagulant and replacement fluid administration review. Ensure adequate blood level in the drip chamber. Prepare to end the therapy. . Possible faulty transducer




Prepare to end treatment

Stop the treatment and report the breakdown.

High pre filter pressure (The pre filter pressure exceeds

the upper alarm limit of 400mmHg)

Check filter for signs of clotting Blood flow is too low Line is occluded Clamps left on Faulty pre filter pressure sensor.

Access line is “kicking” Visible clots in the filter Visible clots in return chamber Check clotting Consider Increasing pre-dilution 3 consecutive high pre filter pressure alarms, consider ending the treatment. Ensure adequate blood flow. Check line set for narrow sections Check access line for kinks or clamps. Check pressure sensor





Air detected

Air or micro-foam visible in the drip chamber or Return line. The return line is not properly positioned in the air detector. The blood level is too low in the drip chamber. Air detector sensors are dirty. Marks on the return line. Check all connections, including access, filter and Heparin connections for sources of air leaks. Ensure both seals on the Accusol bag/s are broken, bag/s are spiked, all clamps are open, lines are not trapped or kinked. The air detector is faulty.

Remove air from the drip chamber and Return line.

Ensure Return line tubing is not “pinched” within the air detector.

Raise the blood level in the drip chamber. Clean the sensors. Ensure line is not pinched within the air detector.

Ensure all connections are secure and patent.

To remove air from the line: Step1. Attach syringe to the top of the return chamber after carefully releasing the pressure from the line. Step 2. Press the “clamp key” to open the return line clamp.

Step 3. Remove all air from the return chamber with the syringe. Step 4. Confirm the tubing is correctly inserted into the air detector Step 5. If level in the drip chamber is correct and the bubbles are out of the tubing, press the “clamp key” to close the return line clamp. Step 6. Resume treatment by pressing the blood pump key. Step 7. Monitor and control the level in the drip chamber




Balance alarm Check substitution/dialysate

line

Or

Balance alarm Check filtration/effluent line

Counted balance alarm: The patient’s fluid balance deviates more than 50 g in adult treatment or 20 g in pediatric treatment for more than 15s. The deviation is less than 120 g The deviation could not be compensated during TFL Review UF variation in More screen. Non counted balance alarm:

The patient’s fluid balance deviates more than 120 g for more than 15 seconds.

All clamps are open. Lines and bags are hanging freely. Lines and bags are not kinked, clamped or blocked. Bag connections are correct Bags and lines are not resting on the cart frame Bags are not swinging. Lines on the manifold are all unclamped. Accusol bags are spiked. Seals are broken on the Accusol bags. Ensure connections are secure and fluid is not leaking from the bags Avoid touching the filtrate or substitution bags while the treatment is running. Avoid adding or removing bags while the therapy is running. Avoid moving the Aquarius system while the Balance system is active. Reduce the number of substitution/dialysate bags Bags are swinging on scales or touching the cart frame of the Aquarius. When multiple bags are hung on the scale, if the bags are touching each other or the tubing lines are resting on the cart frame, the draining of the bags can cause them to shift position, resulting in a temporary weight change A bag is detached from the scale.

Adding or removing a bag without stopping the Balance system. Moving the Aquarius system while the balance system is active.

Restart the treatment

Note: If 5 counted balance alarms occurred during the 20 minute window period it will not be possible to resume the treatment. Follow the onscreen instructions to end the treatment. If no further alarms are shown for a period of 20 minutes, the balance alarm counter will reset to zero.




Alarm Cause Options for error removal Action Blood Leak Blood leak chamber not filled with fluid.

During set up, the blood leak chamber has been removed from its housing. Dust on the mirror. Mirror is cracked or missing. Filter membrane is damaged / ruptured.

During lining go to “reprime” and choose ultrafiltrate line. Ensure filtrate line is securely connected. Ensure there are no kinks/narrow sections on the line. Check lining within pump housing Ensure there are no scratches/marks on the chamber. Reposition the blood leak chamber. Remove mirror. Clean and replace as found. Do not clean the infrared light.

It is not recommended to use a mirror from another device. Report the breakdown

Filtrate / plasma contains blood. (Note: Ultrafiltrate typically is a rose colour) Check BLD % reading in MORE screen. Consider doing a urine dipstick to confirm the presence of blood. Discontinue treatment and change circuit.

Restart the treatment.

Select Options and End treatment, follow the on-screen instructions to wash back and end the treatment.




High TMP (-50 to +450mmHg)

TMP has risen slowly – filter is clogging. TMP has risen rapidly – filtrate line or bags clamped or kinked. High TMP from the start of therapy

Reduce post-dilution flow rate and increase pre-dilution flow rate. Review anti-coagulation. Check blood flow / exchange ratio. Increase blood flow rate accordingly. Unclamp or remove kink from line.

Check blood flow / exchange ratio. Increase blood flow rate accordingly.


.

Low TMP Filtrate pump runs slower than the treatment pumps. The filtrate line is closed between the filter/kidney and waste/effluent bag/s.

Modify blood flow rate and/or fluid exchange. Check filtrate line is not kinked, clamped or twisted. Line is not “pinched” within the pump housing.


.

Pressure test disabled Air detection system does not detect

“free air” in the tubing. (The clamp and pressure test is disabled.)

Make sure that the return line does not contain air. Make sure that the return line is properly installed in the air detector and that the air detector is pushed in. Ensure that the return line is not

scratched. Re-prime the blood line.

Restart the pressure test.




No fluid chamber detected The degassing chamber (ADU) is not inserted.

Ensure the ADU chamber is sitting on the pressure switch. (Black and red switch) Ensure the fixation clip is in a horizontal position and closed around the short tubing of the ADU.


Check Degassing Chamber

(Position: Short line towards the back and long line at the front.)

The ADU worked for more than 25s

without detecting fluid in the chamber. The hydrophobic filter on the ADU sensor line is wet.

(Measured pressure < –ve 300 mmHg).

The system detects a positive pressure higher than +30 mmHg. Fluid is detected in the ADU sensor line.

Check all clamps on the substitution/dialysate line are unclamped. Check the substitution/dialysate line is not kinked. If using a manifold ensure lines are not clamped or kinked. Check if the frangible pins on the bags are broken. Ensure both seals on the Accusol bag are broken. Ensure lines are not trapped under the heater door. (Ensure heater coil is

positioned with the smooth side against the heater plate and the lines are in a horizontal position.)

Use line tidies on the ADU or integrated syringe driver to position lines in order to prevent kinking of the lines. Ensure ADU is in the

correction position. (Short

line towards the back and long line at the front.)

To remove fluid from the sensor line (long line with green clamp):

Step1: Clamp the line. Step2: Disconnect line from the sensor and hold the line up. Step3: Attach a 10ml syringe, unclamp the green clamp and push air into the line until the line is clear of any water. Step4: Clamp the line again, remove the syringe and attach line to the sensor. Step5: Lift the chamber up from the pressure switch and push the chamber down again. Ensure the fixation plate is pushed down around the short tubing. Step6: Unclamp the green clamp.

Press the mute button (to reset

the alarm)

and restart the treatment.




Change substitution/dialysate bag

OR

Change filtrate/effluent bag

The substitution/dialysate bag/s are

nearly empty (approx. 150mls left per bag)

The filtrate bag has reached maximum permissible weight

Change the bag/s. Change the bag/s


Check transducer connections

The pressure domes have not detected

any pressure change for 15 seconds. Ensure the domes are securely connected. IMPORTANT: do not remove any pressure sensors during treatment. If domes are in place, consider increasing blood pump or treatment pump rates.


Turnover Failure (Balance pump speeds are

consistently higher or lower than the programmed speed for more than 20 consecutive minutes to ensure accurate fluid delivery.)

Fluid leaking from bags. Incorrect line installation Incorrect bag installation. Pump calibration out of range Filter inappropriate for fluid delivery rates.

Ensure all connections are securely attached and patent. Ensure lines are not kinked, clamps are unclamped, and lines are not twisted. Bag/s is not spiked, spike or frangible pin is blocking the flow of fluid, bag/s is not hanging freely, or bags are swinging. Report the breakdown. Consider using a different size filter.

Restart the treatment.

Heater cools down Balance system has stopped for more than 15 s and the heater plate temperature is above 43°C.

Ensure the balance system is active. The treatment is paused until the temperature returns to normal.

Substitution pumps will run at a slow rate to help cooling, taking priority over Total Fluid Loss compensation.

Active cool down management may take up to 10 minutes. The treatment will restart automatically.




Less common Alarms.

System Test Failure Ensure both pump doors are closed

Ensure no bags are hanging on the

scales.

Close the door/s.

Remove bag/s from the

scales

Press the blood pump to restart

the self test.

If machine fails test again,

switch the machine off and

unplug from the wall. Leave the

machine for 15 minutes and put

the machine through self test

again.

If it still fails note the message

on the screen and report the

breakdown.

Heparin Pump (Actual values of control and

protective systems are outside of their limits.)

The plunger is incorrectly positioned. Heparin driver is making a grinding sound Whistling sound coming from the Heparin line.

During Self test/Start up, ensure no line set is installed During treatment:

1. Check the heparin line is

not clamped. 2. Go to "Options" and "Change Syringe", following the on-screen text. Note: It is NOT necessary to remove the syringe during this process 3. If problem persists, program the pump to 0, clamp the line and remove the syringe. Ensure Heparin line is not clamped. Ensure Heparin line is clamped and capped if not in use.

If the error cannot be reset, put system out of operation and notify technical support.




No Bag (Less than 45g are detected per

scale.)

No bag/s on the waste/filtrate scale. Bag weighs less than 45g. Lines or the manifold is touching the

frame of the machine

Lines are twisted.

Filtrate line is clamped

Self test was performed with bag/s hanging on the scales. Number of bags programmed is

different from number of bag/s

actually hanging on the scales

Place bag/s on the scale. Use a bag weighing more than 45g. Note: It is not recommended to re-use used/empty Accusol bags. Ensure lines and the manifold is not touching the frame of the machine. Straighten/un-twist the line. Unclamp the line. Remove bag/s from the scales and repeat the self test

Use an additional bag on each scale: - Go to “Programming” window. - Program 2 bags. - Ensure that 2 empty effluent bags are hanging on the filtration scale and connect both filtration bags to the filtrate line. - Ensure that 2 substitution bags are hanging on the substitution scale and connect both substitution bags to the

Programme correct number of bags as per scale.

Restart the treatment pumps

Master key transfer

Keyboard Failure

Operation Mode

A key press longer than 60 seconds was detected Short disturbances in the communication between the master and the controller CPU.

The alarms are to notify the user that an issue occurred).

Clear the alarms by pressing the blood pump key.

If the alarms do not clear, Report the breakdown.

Blood Flow Failure The number of revolutions of the pump

exceeds or falls below the alarm limits by ± 5%.

Check the blood flow rate

Check blood pump tubing is not twisted/pinched within the pump housing Check the tubing for narrow sections/clamps

Press the blood pump to restart the treatment.




Notes:




1. Citrate and Prostacyclin Anticoagulation

Discussion and demonstration.

Pre – course exercise: Please make notes on one of the following subjects

Consider the ‘state of the art’ for anticoagulation in your PICU: How do we choose Heparin,

No Anticoagulation or an alternative modality?

Citrate and Predilution, what we could learn from experience in Adult ICU, and where might

this lead our patient care?

The decision tree is a visual aid to map your thoughts

Top Tips: An Aquarius System PCRRT Workshop handbook 1 ... · Top Tips: An Aquarius System PCRRT Workshop handbook AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd. PM-0032-06/2015.

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