2017 version 1 1

CRRTONPICUAquick‘howtoguide’forPICUnurses&HCP

Zoomgraphicsandtrouble-shootingguideonfilterfordetailedinformation

24/7helpline:07623945987Whenyoucall,leavethenameofthepersontheyshould

contact,sayitisPICUatStGeorgesHospitalcalling,give

themthenumberofthehands-freephonesoyoucantake

thecallwhentheycallyoubackfortrouble-shooting,and

asummaryoftheproblemyouarefacing.Therepwillcall

youbackandworkthroughproblem-solvingwithyou.

Themostcurrentnumberisdisplayedonallhaemofilters.

Pleasenote:Forourverysmallpatients,ourfirstoptionistoadministeracontrolled

blood transfusion rather than blood prime the circuit. Discuss this option with

consultants. The blood prime protocol is at the end of this document.

2017 version 1 2

WHATINEED

o ThefiltermachinefromGICUorCTICU

o Correct size aquamax filter & filter circuit (there are 3 sizes: 2 paediatric:

AqualineS,1adult:Aqualine)

o Replacementfluid(withorwithoutpotassium)

o Wastefluidbag

o 0.9%salineforpriming(1litre)

o Heparinforprimingfluid(ifnotcontraindicated)&makingupinfusion

o Salineforflushinglumens

o Steriletrolleyanddressingpack

o Extragauzeifsecondnursenotavailabletoassistas‘dirtynurse’

o 4X10mlsyringesforaspiratinglumensandflushinglumens

o Sterilegloves

o BlueclampsX2(toclamplinesinemergencywhenyouattachchild)

o 3waytapandspike(forrecirculationanddisconnection)

o Whitebungs

o PPE

o Prescriptions

o Paperworkforcalculatingturnover,bloodpumpspeed&fluidbalance

EMERGENCYTRAY

Setupemergencytraylaterwith:heparinforheplock,4X10mlsyringesandflushesfor

aspirating&flushing,20mlluerlocksyringefortrouble-shooting,blueclampsX2ifnot

already available, dressing pack, sterile gauze& sterile gloves, 500mls normal saline

with3waytapforreturningbloodorrecirculating,2mlsyringesX2,whitebungs.

2017 version 1 3

CAREOFVASCATHandSITE

Thefemoralorrightinternaljugularsiteisthemostcommonsiteforvascathinsertion.

v InternaljugularlinesmustbeX-rayed,positioncheckedanddocumentedbydoctors

priortouse.

v PerformabloodgasandcheckasaninitialsteptopreventunnecessaryX-Rays.

v Transducethevascathlinetocheckwaveform-MUSTNOTbearterialwaveform(more

reliablethanabloodgas).

v Checkperfusionoflimbdistaltofemorallinesandcheckpedalpulsesminimum4hourly

v DressthelinewithaclearocclusivedressingwiththeinsertionsitevisibleasperTrust

policy.

v CleanthesiteasforanyinvasivelineasperTrustpolicy.

v Alwaysaspiratethelinebeforeflushingwithnormalsaline(0.9%)usingpositive

pressureflushingmethod.

v Ifthevascathisnotinusewithinafewminutesofinsertion,heplockwith1:1000

heparinaccordingtothevolumesstatedinthevascathlumenandapplyalabelto

indicatethelineisheplocked.ALWAYSassumethevascathisheplockedandinform

others(e.g.goingtotheatre/CTscan)

v PerformlineandsitesurveillancechecksanddocumentonlinesandtubesasperTrust

protocol.

v Ourstandard:CRRTmustbecommencedwithin2hoursoncecorrectvascathposition

hasbeendeterminedandthemedicalinstructiontostartCRRTisgiven.

v Asterile(surgicalANTT)isusedwhenaccessingthevascath.

v Asaruleofthumb:youshouldbeabletowithdraw10mlsoffluidin3secondsand20

mlsin6secondsfromvascathforgoodflowfromanadultvascath.Thisequatestoa

bloodflowrateof200ml/min.

v Forthetriplelumenvascath,anythinginfusedintothethirdlumenwillbefilteredoff

v Swappinglumens:Normallythereisa5%recirculationofbloodbetweenthelumens.If

thelumenisswapped,thisisincreasedby20-40%(moreformuchsmallerlines).

Clearancewillbeaffected.Swappingisnotrecommendedandusedasalastresort.A

newvascathmayberequired.

v SeeDr’sprotocolonvascathlines.

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v ThemanualkeylocatedatthebottomofthefilterisONLYtobeusedinthecaseof

powerfailureandyouareaimingtoreturnbloodbacktothepatient.

FiltersTherearethreesizesoffilteravailableonPICU

1. HF03

2. HF07.Thiscansuccessfullyfilterupto60Kgchild.

3. HF1260kgandover(adultsize)

Patientsize Filtersize Filtervolume LinesVolume Blood flow rate/Blood pump speed

(BFR/BPS).This isanoverview.CheckPICU

flow rate/turnover chart for detailed

informationonmanagement

0-5kg HF03 32ml 61ml 15-50mls/minup to 80ml/min if child

tolerates

5-15kg HF03 32ml 61ml 100mls/min

15-40kg HF03

Consider

HF07(20Kg)

32ml 61ml 150mls/min(15-30kgchild)or

200mls/min(>30kgchild)

>40-60kg HF07 49ml 61ml

Ifusing

Aqualine(not

S)then100ml

200mls/min (>30 kg child) see section on

clotting and ‘useful calculations’ section to

addendum to increase flow rates if filter

clottingtoomuch

>60kg HF12

HF1973

109

100ml Up to 350mls/min (adult size). Choose

AqualineNOTAqualineSonfiltersetup.

HF03andHF07:AqualineS(paediatricsizes)

HF12:Aqualine(adultsize)

Bloodflowrate:maximum6ml/kg/min.Lessthan5kgmayrequirebloodprime/controlled

bloodtransfusion.Lessthan3kgmayneedtogoupto7ml/kg/minBFR.

MinimumBFR3ml/kg/hr:morelikelytoclogandclot.

ConsiderHF07for10-30kgchildren.

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YoucanchangefiltersandBPStomeettheneedsofthechild,particularlyifthefilteris

clottingfrequentlyand/orifyourultrafiltrateistoolargeforyourBPS.Youneedto

considerchild’scirculatingvolume(so8ml/kgcanbesafelyextracorporeal)andHbto

determinewhichfiltersizetouse.ThemaindifferencewillbebetweenHF03andHF07

foroursmallchildren.LookatsuggestionsunderclottingandTMPalarmsandthe

‘usefultips’onhowtocalculatebloodflowrateandfiltersizeandresetthese.

PRE-USECHECKS:Thefilterisreadyforliningwhen:

o Thereisastaticgreenlight

o There is a static orange light. DO NOT rush this stage as there will be a CPU

heatingalarm if theheaterhasnotyetcomeonand thewholeprocedurewill

havetobere-commencedagainfromthestart.

o If the yellow status light is still flashing after the system test is finished, the

heater self-test is still running. Entering theprimingprocessbefore theheater

self-test is finished is not possible. The yellow light stops flashing when the

heaterself-testisfinished.Afterthatselectthetherapy(CVVH)andconfirm.

o Thereisanaudiblealarmindicatingthemachineisready

o Themachinehaspassedtheself-test

STEPS INLININGTHEHAEMOFILTER:usezoomgraphicsprompts.Belowaresome ‘quick-fix’

suggestionsforsuccessfulset-upandprolongyoursetlife.Thereisanotherfolderwithmore

extensive‘trouble-shooting’ifneeded.

Alwaysplugthemachineintoanuninterruptedpowerswitch.Switchthemachineon.MachineperformsSystemTest.Thistakesapproximately4minutes.Intheinterim,youcanpreparetheprimingfluidandinfusions.Allpumpdoorsmustbeclosedatthisstage(theself-testwillfailifanyofthedoorsarenotproperlyclickedshut.TheAquariusTMsystemtestmustbeperformedbeforeliningthedevice.Thepumpdoorsmustbeclosedandnoreplacement/dialysateorwastebagsmustbeplacedontherelevantscales.

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Iftheself-testfails:

Ø Tryopeningandre-shuttingthedoorandseeifthisresolvestheproblemØ Waitafewminutesandforpumptoresetandthenretest.Maximumre-test:

3timesthentakeitoutofcirculationandinformcompany/technician.

Ø Check all doors are clicked shut and try again if you can for pump CPU1

failures.

Ø Suggestion:UnplugtheAquariusmachinefromthemainpowersupplyfor15min.Afterthat,switchthemachineonandrepeattheself-test.

1. Selecttherapye.g.CVVH(themostcommonmodeusedonPICU)

2. Selectthecorrecttubing.Paediatriccircuits:AquilineS.Adultcircuits:AQUILINE

3. UsePPE/infectioncontrolasperpolicy

4. Twochecksmustbedoneonceyouhavestalledthetubing:

Ø Drycheck:beforeprimingcheckyourset-upcarefully

Ø Wetcheck:afterprimingcheckdegassingchamber,blood leakchamber

anddripchamberarefluid-filled.

Installtubing(usezoomgraphicswhichtakesyouthrougheachstage)

Ø We use “Aqualine S” sets for all paediatric circuits (HF03 & HF07) and

“Aqualine”foradultcircuit(HF12).Youwillhavetoobtainthisfromadult

ICU.

Ø Priming tubes andbags are colour-coded.Red-to-red, yellow to yellow,

green to green. The blue line (return line) is attached to your priming

fluid. So fluid is pulled through the return line. This is because priming

occurs inanoppositedirection to treatmentmode.Duringpriming, the

blood pump will be spinning against the direction of the arrow.In

treatment mode, the access line is red and pulls blood i.e. through

negativepressureintothecircuitandthisisreturnedviathebluelineon

thefilter.So,thebloodpumpwillbespinningclockwise/inthedirection

ofthearrowdisplayedontheredpump.

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Ø DoNOThandletheblood leakchamberas itmaytriggertheblood leak

alarm.Ifitalarmscleanitwithapapertowelandreinsert.Ifitstillalarms

then follow the trouble-shooting guide on the machine for this

component.

Ø Sitthepressuretransducer(Yellowpressuredome)nexttothebloodleak

detectionchamberina‘7past7’position.Thiswillsitthebloodleak

chambermoresecurelysothatitislesslikelytopopoutofitshold.Ifitdoes

popoutthe<bloodleak>alarmwillbeactivated.Popitbackinproperly.

Ø Fixthedegassingchamberintoitsfunctionalpositionmakingsurethe

shortestlineistowardsthebackclosesttothemachine.Ensurechamber

coverisclosedsecurely,aroundthetubing.Note:iffixationclipisnot

securelyclosedtherewillbea<degassingchambermissingornofluid

chamberdetected>alarmattheendofpriming.YoumusthearaCLICKas

youattachitandmakesurethechamberissittingontheswitch.

Ø So,PlacedegassingchamberintheADUand:Ensurethefixationplateis

inhorizontalpositionandclosedaroundtheshorttubingwiththegreen

clampatthetopoftheADU.Ensurethemagnetontheundersideofthe

fixationplateisnotmissing.Ensurethismagnetisnotdirty.Ensurethe

ADUchamberissittingonthepressureswitch(blackandredswitchat

thebottomoftheADUunit).

Ø Connectdegassingline(ithasaclamp)topressuredome(sensor).Connect

theluer-lockhydrophobicfilterfromtheADUlongerdegassinglineto

theADUsilverpressuremonitor.Ifthisisnotsecurelyattached,itwill

entrain/suckinalotofairintotheheatercircuitifitbecomeslooseduring

therapy.DONOTPANIC.Usea50mlsyringetoaspiratetheairANDTHE

CHAMBERWILLFILLUPAGAINbutmakesureyouclampthelinebefore

andafteraspiratingandunclampitonlyafterfixingitbackoritwillentrain

airagain.

Ø TheADUisautomaticanditwillberemovingthesmallamountofair

(CO2)inthesteps.However,iftheheatercoilisfilledwithairduetothe

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usererror,youmightneedtohelptheADUanduse50mlsyringeto

aspiratetheairfromtheheatercoilviatheshorttubingtopreventits

escapetopreandpostdilutionline.Donotpanic,ifitescapes,theair

wouldaccumulateinthedripchamber.Itcouldescapefromtheretothe

airdetectorbutthesafetymechanismofthemachinewouldclampthe

circuit.Youcouldtroubleshootorcalltheclinicalpager.

Ø Locatereturnlinewhichhasthedripchamber/bubbletrapconnectedtoit,

ensurethatthisisinsertedundertheairdetector.

Ø Pushandlockthepriminglineagainsttheairdetectordome(sensor)

groove.

Ø Attachpressuredomes.Clampsonthepressuredomemustbenicelytight

andclickedintoplace.ThePRE-FILTERTUBINGhasthehighestpressureand

slowsflowofthebloodpumpspeed.Checkthatthepressureclamp(gate)is

securelyclosed

Ø AlcoholwipesshouldNOTbeusedtocleanthegates/clampsoranyother

partastheresiduemakesitsticky.Useawaterandpapertowel.

Ø Placepre-filtertubing(REDDOME)aroundpre-filterpressuredomeina

‘takedogforwalk’position.Seetheillustrationonzoomgraphics.

Ø Placehaemofilter(kidney)inholder–REMEMBER:REDtotheTOPandBLUE

totheBOTTOM.

Ø Topgreenpumpisthepost-dilutionpump.

Ø Bottomgreenpumpispre-dilution.Wedo100%pre-dilutiononPICU.Ifyou

needpost-dilutionseeadultprotocolordo50/50.

Ø Donothangmorethanonewastebag(yellowline)andonesubstitutionbag

(greenline)onthehangingpolesatthebottomofthefiltertoprevent

movingandhandlinginjuries.Amovingandhandlingriskassessmentmust

beperformedanddocumentedifyouusemorethanonebagatanytime.In

thiscase,youwillneedthemulti-spike(borrowedfromtheadultunits)

Ø Donotre-usesubstitutionbagsforultra-filtratewastebag

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Ø Bungoffandclamptheanti-coagulationlineifyouarenotusingitwitha

PICUwhitebung.Ifyouhearawhistlingnoise,thismaybebecausetheline

isdrawingairin.Youcanflushthelinewithnormalsalinebutclamptheline

andchangethebung.

5. PRIME CIRCUIT: Heparin 5000 units in 1 (one) litre 0.9% normal

salineforprimingORprimewithheparinthenreprimewithnormal

salineORprimewithnormalsalineonly(consultantchoice)

6. CLAMP&PRESSUREtestusingtheguideonthemachine.IfaCPUalarmoccurs,

thenreprimetheblood-side.Ensurethereturnandaccesspressuregatesatthe

bottomendofthemachineareproperlyclosed.Sometimesthereisanair-lockin

the pressure dome, give this a couple of flicks and ensure everything is

tightened.

7. RecirculateataBFRof50ml/hrforatleast20minutespriortoconnection.This

willhelptofully‘wet’thefilterfibres.(thedefaultis10mlssoincreasetherate)

8. Turn the machine OFF until you are ready to start treatment (not for blood

prime).Bloodprime:startthetreatmentassoonasthecircuithasbeenprimed

withblood.Onlybloodprimewhenyouarereadytocommencetreatment.

9. Calculateyourfluidsandsettreatmentparameters.

10. Ensure the treatmentandall infusions,priming fluidandotherparametersare

prescribedandsignedforpriortocommencingtreatment.

11. Wheninstructedtostarttreatment,observepatienttoleranceandtheir

haemodynamicswhichmaybecomeunstable.Haveabolusoffluidavailableor

inotropesifrequired.Poorintravascularcirculationorbloodpressurewillcause

filtrationproblems.

12. Prepareyouremergencyaccesstraywithsalineampoules,10mlsyringes,gauze,

blueclamps,alcowipes,sterilespikeand3-waytap,goggles/visorandsterile

gloves.AccessingyourvascathisaSTERILEprocedure(surgicalANTT).

2017 version 1 10

13. Heparininfusionmustbeprescribed(thisistheinfusion-notpriming).

Ø Standardinfusion:100units/kgin50mlsnormal(0.9%)saline

Ø Normalrateis5ml/hr(10units/kg/hr)

Ø SeeprotocolforheparinmanagementonDR’sprotocolattachedtothis

document.

Prostacycline(PGI2)(FLOLAN/EPOPROSTENOL)NB:CANNOTBEUSEDINSYRINGEDRIVERBUILTINTOAQUARIUSPrimethegivingsetandattachittofilteranticoagulantline.Onlyusedwhenthereisevidenceofabnormalplateletactivityandwhenspecificallyrequestedbyconsultant.ThisisaProstanoid,whichisapotentinhibitorofplateletactivationandworksbyreducingplateletaggregation.Ithasnoothereffectontheclottingprocess.Onelimitingsideeffectissystemicvasodilation.Donotbolusthedrug.Ifthelinehasbeenclamped,reducetheratefirstbeforeunclamping.Increaseratetonormaloncestable.Systemicvasodilationcancauseunstablehypotension.Haveabolusoffluidavailableand/orinotropes.Approximately40%willbefilteredoutduringCVVHtreatmentBeforeincreasingtheinfusionabove15ng/kg/minconsideraddingHeparin(unlesscontraindicated),whilstacceptingthatthechild’sconditionmaynecessitatemorefrequentcircuitchangesProstacycline(PGI2)Standardinfusion:100,000nanograms:i.e.10mlofthepreparedsolutionmadeupto50mlwith0.9%normalsaline=2000nanograms/mlandrunat5-10nanograms/kg/min.NEVERBOLUSprostacyclineinfusionasitcancauseunstablehypotension.Monitorpatients’BPverycloselywhenfirstc0mmencingthisdrug.Neverreleaseanyclampssuddenlywithoutfirstreducingtherateasthiswillcauseabolusofdrugandlife-threateninghypotensionPreparedflolancanbekeptinthefridgewithpatientsnameanddetails

Argatroban: short-acting, synthetic, direct thrombin inhibitor with anti-coagulant and

antiplateletactivity.SeekadultITUguidelines/adviceifusedforCRRT.

RECIRCULATION

2017 version 1 11

14. Attachpatientsnameanddate/timethefilter.Therecirculatedfluid isvalidup

to24hours.After24hours,re-primethecircuitagain,andrecirculatethesetfor

twominutesbeforestartingtreatment.

15. If the set is being recirculated following treatment, and the blood has been

washedback,this isvalid foronlyonehour.Youcanrecirculatemultipletimes

butonlyforamaximumofonehouratatime.

16. Toend treatment, go toend treatment sectionand follow theprompts.Make

verysureyoureallywanttoendtreatmentasyoucannotundothisonceithas

beeninitiated.

RETURNINGBLOOD:Itmaynotbeappropriatetoreturnpatient’sbloodinallcases(e.g.

in case of overload) when ending treatment. Remember that once the child is

establishedontothefilter,youareessentiallygivingarapidfluidboluswhenyoureturn

bloodtothepatient.Thoseparticularlyatriskarecardiovascularlyunstablepatientsand

smallbabies.ALWAYSriskassessanddiscusswithconsultant/doctorsfirst.

PREANDPOST-DILUTION

Sometimesweusepost-dilution.Ifthisisthecaseuse½pre-dilutionand½post-

dilution.PostdilutionisAccusolthatwegiveafterthefilterandbeforethedrip

chamber.IthelpstopreventclottingintheDRIPCHAMBER.Butitalsomeanstheblood

inthefilterislessdiluteaswepulloffmorewasteproductsfromthebloodresultingin

bettersoluteclearance.

Foradultformula:ratioofpretopostis:1/3rdAccusolaspre-dilutionand2/3rdpost-

dilution.Sofor3000mlexchange:1000mlpreand2000mlpost-dilution.Thisratiois

changediftherearesignsofthefilterclottingorcloggingso:decreasepost-dilutionand

increasepre-dilutiontomakethebloodmorediluteasitmovesthroughthefilterandso

lesslikelytoclotorclog.

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ThisisthedefaultprotocolonPICUBFRwhichincludesalsoturnovervolumes.Spare

copiesareinthisfolder.Pleasereplaceifyouhaveusedthelastcopy.

YoucanincreasetheBFRifhighervolumesarerequired.Seesectionon‘clotting’and

informationon‘usefulcalculationsforhowthisisdone.Considerthechild’scirculating

volumesandHbwhenchoosingthehighervolume/largerfilterwhenchangingthis

protocol.

2017 version 1 13

CommonalarmsAdditionaltroubleshootingavailableon:www.gicu.sgul.ac.uk/resources-for-current-staff

Tipsfortroubleshootingarealsointhefolder‘CRRTTrouble-shooting’ateachbedside.BLOOD LEAK ALARM: The blood leak detector alarm is a safety mechanism. It detects

molecules2mlofbloodin1000mls. Ifthere isatrueBLOODLEAK,therewillbebloodin

thefiltrate(yellowline).Wastemayappearrose-coloured.Causesofbloodleakalarm:

•Filtrate/plasmacontainblood.

•Filtermembraneisdamaged/ruptured.

•DuringtreatmenttheBLDchamberhasbeenremovedfromitshousing.

•BLDchambernotfilledwithfluid.

Troubleshoot:

CleanandrepositiontheBLDchamber.

Goto“reprime”andchooseultrafiltrateline.

Removemirrorandcleanandreplaceasfound

Afterprimingmake sure theblood leak chamber is filledwith fluid. If the chamber isnot

FULLattachanewbagofsalinetoreturnlineandreprimethefiltratelineusingthereprime

option.

Ifthebloodleakalarmistriggered,performadipsticktestforbloodfromfluidinthewaste

bagtocheckforbloodleak.Thebloodleakalarmmaybeactivatedbycontaminantsoutside

thechamber.Cleanthechamberwithwarmwaterandpapertowel.NOalcoholwipesasit

canleavearesidueandthiscantriggerthealarm.Ifthealarmisstillactive,popthemirror

outofitssocketintheholdingchamberwithouttouchingtheactualmirror(takingnoteof

whichwaythemirrorwasactuallysituatedasthisisthewaythemachinewouldhavebeen

calibratedbythecompany)cleanitandreplaceitintheSAMEwayasitwastakenout.

Ifthemirroriscracked,themachineisoutofuse.Calltherep(numberonfiltermachine).

Anengineerwill attend tochange themirrorand recalibrate the filtermachine for future

use.

2017 version 1 14

INSERT DEGASSING CHAMBER: Use zoom graphics for positioning the degassing

chamber.Ananalogy‘elephanttrunktofront,earsonsideandtailattheback’position

-thispositionallowsthemagnettoseethechamber.

Thegatingmechanismmustbeproperlyclosedandyoumusthear itCLICK intoplace

(the elephant’s bottom needs to click to sit otherwise you will get an ‘INSERT

DEGASSINGCHAMBER’alarm.

NOFLUIDCHAMBERDETECTED (the ADU chamber is not inserted correctly). PlacedegassingchamberintheADUand:

EnsurethefixationplateisinhorizontalpositionandclosedaroundtheshorttubingwiththegreenclampatthetopoftheADU.

Ensurethemagnetontheundersideofthefixationplateisnotmissing.Ensurethismagnetisnotdirty.EnsuretheADUchamberissittingonthepressureswitch(blackandredswitchat

thebottomoftheADUunit)

CHECKDEGASSINGCHAMBER:DONOTpressthemutekey.

TheADUhasnotdetectedanyfluidinthechamberorfluidinthechamberisdown=>

lookDOWN.

Checkallclampsonthesubstitution/dialysatelineareunclamped.

Checkthesubstitution/dialysatelineisnotkinked.

Ifusingamanifoldensurelinesarenotclampedorkinked.NOTE:Ifthereisacounted

balancealarmpresentandmultiplebagsareoneachscale,considerrevertingbackto

onebagperscalewithoutthemanifold.

EnsurebothsealsontheAccusolbag/sarebroken.

Ensure lines are not trappedunder the heater door. (Ensure heater coil is positioned

withthesmoothsideagainsttheheaterplateandthelinesareinahorizontalposition.).

Ensurethereisnoairlockintheheatercoil.

CheckiftheClampexontheAccusolbag/shasbeenopenedtofluidflow

Thelevelofthefluidisup=>lookatUP-atADU

2017 version 1 15

ThehydrophobicfilterontheADUsensor/degassing line(the longtubingatthefront

withgreenclamp)arewet

Troubleshoot:

1.ClampthelongtubinglineatthefrontoftheADU.

2.Disconnectlinefromthesensorandholdthelineup,soitisvertical.

3.Attacha10mlsyringetotheendoftheline,unclampthegreenclampandpushair

intothelineuntilthelineisclearofanywater.

4.Clampthelineagain,removethesyringeandre-attachthelinetothesensor.

5. Lift the chamber up from the pressure switch and push the chamber down again.

Ensurethefixationplateispusheddownaroundtheshorttubing.

6.Unclampthegreenclamp.

7.Pressthemutekeytoresetthealarmandrestartthetreatment.

Iftheelephanttrunkisrotated,thetrunkmayfillwithfluidandthehydrophobicfilter

becomes damp. If this occurs, clamp this line, flush the fluid back into the chamber,

position the elephant trunk carefully with no kinks, etc and reset the degassing

chamber,unclampthetrunkonceyouhaverestartedtreatment.

Ifyouneedtodetachthehydrophobic filter foranyreason,always,CLAMPITFIRST

ORairwillgointotheheatercoilandsubstitutionline.So,UNCLAMPtheline,PRESS

MUTEKEYonlyafter theproblem is resolvedand thedegassingchamberwill then fill

withfluid.Thefluidadjustsitselfsoyouneednotmanipulatethis.Ifthereisair inthe

substitution line,balancealarmswillbetriggered.Donotmutethebalancealarmsas

youneedtoresolvethisproblemfirst.

Themore common problem: Check the level of fluid in the chamber, look DOWN to

checkSUBSTITUTIONfluidasthisiswherethegasiscomingfromandifthesubstitution

fluidsealisnotcompletelybroken.Commonproblem:substitutionsealsnotcompletely

brokenforthegastoescape.Ifthebagisnotspikedorthesubstitutionfluidsealisnot

2017 version 1 16

completely broken, the machine is unable to pull the fluid from the bag into the

chamber.(Thegascannotescapeifthesensor/degassinglineandhydrophobicfilterare

wet)

There may be an air-lock in the heater circuit especially if you have high exchange

(turnover) on low blood pump speed (BPS). For air lock, open heater door, give a

coupleofflickstodislodgeandreleasetheair.Thisshouldresolvetheproblem.

Whenthesubstitutionfluidarrivesattheheatercoil, itreleasescarbondioxidegases.

The degassing chamber stops this gas from moving to the blood part of the line.

Otherwisecalltherepwhowilltalkyouthroughtheproblem.

Always clamp the degassing chamber line before disconnecting from the sensor to

stopairbeingsuckedintotheheatercoil.Releasetheclampbeforestartingtreatment

orsoonafter.Iftheheatercoilhassuckedinairthenusea50mlsyringe,tosuckitout

butremembertoclampthelinefirstandtoreattachitsecurelyafterwardssoitdoes

notsuckairbackin.

Heatercoilisfullofairanddegassingchamberalarmistriggered:Use50mlsyringeto

helpdegassingchamberemptytheair.Ifairisinredlineitwillgointothebubbletrap

soattachasyringeandletairpushtheplungeroutwards.

RESETDEGASSINGCHAMBER:Ifyoupressthemutebuttonfirst,thedegassingchamber

willassumeyouhavesortedtheproblemout,soonlypressitafteryouhavesorteditto

resetthisalarm.

DoNOTchangethebungonthebubbletrapofthereturn(blue) lineunlessyouhave

handleditthenchangetosterilebung.

DoNOTclampthedegassingchamberlineunlessyouaretrouble-shooting

2017 version 1 17

Prefilterpressurealarm

Lowpre-filteralarm

Checktheprefiltersensor(dome)duringpriming.Thisdomemayhavedrawninairand

theaircansticktothesensor.Checkallyourconnectionseverywherewhilstprimingin

casethereisalooseconnectionthatisdrawingairin.Tapthetubingacoupleoftimes

todislodgeanyairthatmayhavelodgedinthesensorduringpriming.

Highpre-filteralarm

Returnlinemaybekinkedandthepressurehastravelledallthewayup.

HighTMPalarm

Thisisalateindicatorofclogging.Septicmediators,TPN,lipid-baseddrug,tumourlysis

can cause this problem. The filter is struggling to pull dirty filtrate off.May require

faster blood pump speed (BPS) as usually pre-dilution is already 100% on PICU,

otherwisecanincreasepre-dilution.Checkcoagulationstatusalso.

CheckifchildwilltolerateincreasedBPS,evenanextra10-20mlshigherBPSwillhelp.

Itmaybenecessarytochangefiltersize.

LowTMPalarm

Filtratepressuredome(YELLOWDOME)maybeunabletoreadpressurecorrectly.Press

down on gate clamp securing filtrate pressure dome. DO NOT remove gate clamp-

pressureasitcouldrupture.

Checkthatthefiltratelineisnotclosedbetweenthefilter&thebag

Theremaybeanairlock in the filtrate line.Make sureat theendofpriming that the

wholefiltratelineisprimedwithfluidandthebloodleakdetectorchamberisalsofull.If

notreprimethefiltratecircuittomakesureitis.

2017 version 1 18

Clampoff&disconnecttheeffluentbagandreconnectandunclamptomakesurethe

connectionisallowingfreeflowoffluid.

FiltratepumpmayberunningSLOWERthanthepre-dilutionpump.Considermodifying

the blood flow rate and/or exchange rate. This will impact the blood-flow-to-fluid

removalORblood-flow-to-turnover ratio. Itmaynotbeclinically indicated to increase

thefiltrationfractionandBPSduetopatientcondition,butasthefilter is licensedfor

usein20kgandoverpatients,asmallerchildmayalarmlowTMPandsoahigherBPS

mayberequired.

The machine may have been switched off before filtrate pressure (dome) sensor is

removed.Switchoffanddotheself-testupto3timesthencalltechnician.

HighPressureDrop

Ifthefilterisbeginningtoclot,theremaybeadarkringatthetopoftheredsideofthe

filterand/orthedripchamber.

STOPTHEBLOODPUMP

UNCLAMPDRIPCHAMBERLINE.Thedripchambershouldstarttofillitself.

Thedripchambershouldbeatleast2/3rdfullandnotlessthanthis.

Onrareoccasionsyoumayhavetousea20mlsyringetohelpthedripchambertofill.

CLOTTING

LowBPSandlargerfilter(surfacearea)increasesclottingrisk

Increase blood pump speed/may need larger filter (see section on filter sizes and

‘usefulcalculations’ifnotusingdefaultprotocol)

Manageanticoagulation

Usuallyalreadyon100%pre-dilution,otherwiseincreasepre-dilutionrate

2017 version 1 19

BALANCEALARMS:callrepimmediatelyifyouhavegot3balancealarmsinsuccession

Thisisasafetymechanism.Thealarmisactivatedwhenthereisa20mldiscrepancyin

scalesforpaediatriccircuitand50mldiscrepancyifyouusetheadultcircuit.

Iftheclampison:whatyoutoldthefiltertoremoveandgiveisunbalancedandthere

willbeadiscrepancy,soalarmwillbeactivated.

Ifsubstitutionlineiskinked/occluded,balancealarmsaretriggered.

Checktheclampsespeciallyafterbagchange

Checkthatthelongandshortsealsareproperlybrokeninthesubstitutionbag

Ifthecounterbalancealarmboxcomesup,thereisavariationintheultra-filtrate.This

is todowith thebags swingingormoving.Here,only the filtratepumpspinsand the

problemwillbeclearonthescreenastowhichsidetheproblemis.

TotalFluidLoss(TFL)managementTreatmentpumpsruntoachievetheprogrammedultrafiltrationvolume(orfluidlossvolume).Thebalancescalesmeasurethedifferencebetweenthesubstitutionvolumeandthefiltrationvolume,whichistheultrafiltrationvolume.Abalancealarmoccursinanadultcasewhena20gforpediatric(50gforadult)differenceisdetectedbetweentheprogrammedultrafiltrationvolumeandtheactualultrafiltrationvolume.WhenthepumpsarereactivatedbypressingtheBalanceStart/Stopkey,thevolumediscrepanciesareautomaticallycompensatedforbythesystem.ThisfunctionisTotalFluidLoss(TFL)management.Whenabalancealarmoccurs,ayellowboxwillindicatethenumberofcountedbalancealarmsdetectedduringa20minuteperiod.Ifwithin20minutes5countedbalancealarmsaredetected,aredboxwillbedisplayedtoinformtheoperatorthatthetreatmenthasstopped.Onlythebloodpumpcontinues.AtthistimepresstheNextbutton,togotodisconnectionmode.ThebalancealarmcountwillresettozeroonlyaftertheAquariussystemoperatesfor20minutescontinuouslywithoutstoppingthepumps.Analarmthatstopsthebalancingsystemortheusermanuallystoppingthebalancingsystem,willre-startthe20minuteperiod.Weightdeviationsgreaterthan±120gmaybecausedif,duringtreatment,theuserdoesnotstopthebalancesystemwhenaddingorremovingabagfromthescale,orifthereisalargefluidleak,oriftheAquariussystemismovedwhilethebalancesystemisactive.Althoughthiswillgenerateabalancealarm,thebalancealarmcountwillnotincrease,theUFvariationwillberesettothevaluedisplayedbeforethedeviationoccurred,andtheweightdeviationwillnotbecompensatedwhentreatmentisrestartedbecauseitisnotrelatedtopatientfluiddeviation. Please, look for more info on the Balance Alarm in IFU guide (p 117-118)

2017 version 1 20

BloodPrime:Ifnotusingbloodtransfusionasthefirstoption

v Blood prime is sometimes used if patient is <10kg, but must be discussed with the

consultant on duty. At times, blood primewill be necessary for older childrenwhose

haemoglobinislow.Ourdefaultistodocontrolledbloodtransfusionratherthanblood

primeespeciallyiftheneedtostartCVVHmayoverridetheneedforabloodprimee.g.

in severehyperkalaemia,ormetabolicemergencies,GVHD.Blood transfusioncanalso

beadministeredshortlyafter.Somepatientwillrequirewashedredcells.Checkwith

consultants.

v Oncologypatientsmayrequiremanytransfusionsofbloodproductsduringtheirillness

sotopreventantibodiesformingconsiderwithholdingbloodproductsifnotabsolutely

necessary.

v Blood bank must be informed if you are likely to do perform a blood prime. This is

becauseallchildrenunderthissectionoftheprotocolshouldhaveagroupandsave

and thoseunder10kg (and thosewithvery lowhaemoglobin) shouldhaveaunitof

bloodavailablepriortostartingtreatment.

v Ensurebloodisprescribedandavailable.Informbloodbank.Abloodgivingsetmust

beusedatalltimeswheninfusingbloodintothecircuit.

v Sometimes, you will need to do primewith Human Albumin Solution (HAS) before

hand-discusswithconsultants.Youcanuseaconnectionsocanrunboth intothe

circuit(seebelow)

v DonotinfusebloodintothecircuituntilCVVHisreadytocommence.Thecircuitis

primedwithheparinisedsalineandflushedwithnormalsalinepriortobloodprime.

Theaimistopreventfrothingintheline.

v Oncethecircuit isprimeddonotdelaycommencingCVVHbecausea fewminutes

delaymayresultinthecircuitclotting.

v Use<doubleconnection>thenstepbysteppromptsonzoomgraphics.

v Take blood for FBC, Clotting, U&E’s and ABG as a baseline before commencing

CVVH,astherapyisdependentontheseresults

2017 version 1 21

Bloodprime(adaptedfrom2003SGHPICUprotocol)

1.Youmayneedtoaddheparindirectlytocross-matchedwholebloodandmixwell.Checkthisstepwith

doctorsespeciallyifhepariniscontra-indicated.

2.Forthevolumeofbloodtoorder-calculatethetotalprimingvolumesneededforthecircuitandfilter

beingused.YoucancheckthisontheNikkisowebsite.

3.UseaBLOODGIVINGSET

4.Primethecircuitwithheparinisedsalineasusual

5.ThenfullyprimethecircuitwithHAS

6.ATTHELASTMINUTEputthebloodprimethrough

7.Runthebloodprimethroughuntilitreachestheendofthearterialsideandmostoftheairbubbles

havegone.

8.Choosedoubleconnectionandfollowthesteps

THISISACUMBERSOMEPROCESS-USECONTROLLEDBLOODTRANSFUSIONASOURDEFAULTPROTOCOL.ThePICUstandarddefaultchartsareshownbelow.

2017 version 1 22

Takingthefilterdown

a. Themachinemustbe‘naked’beforeswitchingitoffb. Reducehighpressuresbeforetakingdowntheset.Pressuresmustbelessthan

100mmHgotherwisethereisariskof(bloodfilled)pressuretransducers‘popping’.c. Allcomponentsofthesetaretaken‘down’soplaceanorange(waste)bagonthefloor.

Moveeverythingagainstthearrow.SafeRemovaloftheAqualineTubingSet

a. EnsurethattheAccessandReturnlinesareconnectedtothesalinebagandallclampsareopen.b. Placethesalinebaginadisposalcontainerinfrontofthemachine.c. Ensurethatthefiltrateandthesubstitutionordialysatelinesarestillconnectedtothe

correspondingfiltrateandsubstitutionordialysatebagsandthatbothlinesareunclamped.d. Removethereturnlinefromtheairdetectorandclamp.e. Removethepumptubingsegmentsfromthepumpsinthefollowingorder:

i. Filtratepump(yellow)–indirectionofarrow.ii. Pre-dilutionordialysatepump(green)–inoppositedirectionofarrow.iii. Post-dilutionpump(green)–inoppositedirectionofarrow.iv. Bloodpump(red)–inoppositedirectionofarrow.

f. Checkifpressuresarebelow400mmHg(100mmHgifcircuitclotted).g. Ifnotallpressuresarebelow400mmHg(100mmHgifcircuitclotted),refertotheinstructionsto

decreasepressurelevel.Otherwisecontinueasfollows:h. Disconnectthebagsasfollows:i. Clamptheaccessandreturnlineanddisconnectthesalinesolutionbag.j. Clampthefiltratelineanddisconnectthefiltratebag(s).k. Clampthesubstitutionordialysatelineanddisconnectthesubstitutionordialysatebag(s).

i. DisconnectthehydrophobicconnectorlineofthedegassingchamberfromtheADUunit.

ii. Removetheheatercoillinespiralfromtheheatingunit.iii. Removethebloodleakdetectorpot.iv. Removeallthepressuredomesfromthetransducers.v. RemovethefilterfromtheholderanddiscardcompleteAqualinesetinto

disposalcontainer.l. WhentheAqualinetubingsetiscompletelyremovedfromtheAquariusTMSystem,“Aquariusoff”

canbeconfirmedbypressingtheMainselectorbuttontoswitchtheAquariusoff.Selectandconfirm“Aquariusoff”orpresstheON/OFFkeylocatedontherightsideofthedisplayscreen.

2017 version 1 23

Usefulcalculationsandtips

1. Total blood volume for any weight is calculated using 80ml/kg. So if child is 6 kg, their total

circulatingvolumeis:80X6=480mls.

2. The maximum BFR (blood flow rate) is 8% of the patient’s total circulating volume/min (5-

10ml/kg/min).Sofora6kgchild,8%of480mlsis38.4mlsroundedoffto38mls.

3. Fluidsubstitutionspeedinml/hr:firstchangethe(BPS)fromml/mintoml/hr.Sotimesby60to

getml/hr.BPS inml/hrtimes filtrationfraction/100=substitutionfluidrate inml/hr.Example:

15%FFin6kgchildis:38X60x15/100=342ml/hrsubstitutionfluidspeed.Wegotthe38ml/min

bytaking8%oftotalcirculatingvolume.Socirculatingvolumein6kgchildis480times8%=38ml

(roundedoff).

4. FluidTurnover:This istheamountof fluidthat isremovedfromthebloodarriving inthefilter

per hour. 25% turnover means you remove 25% of the total amount of fluid arriving at the

filter/hour. Higher the turnover, better the clearance. Maximum turnover is 25% of BFR. So

bloodpump speed is set at 100ml/min, then the total amountofbloodarrivingat the filter

everyhouris100X60minutes=6000mls.At25%turnoverthisis25%of6L=1500mls.

5. Turnoveriscalculatedas:PumpspeedX60Xrequiredfiltrationfraction

6. Look for thecorrectbloodpumpspeed(BPS)andcorrect turnoverrateonthepre-setchart in

theCVVHfolderwhenchoosingthistreatmentparameter.Startatthelowestfora2hourcycle

andthenbuildup.Usethepre-setparametersonthechart.

7. Filtration fraction% (FF) A 5-15% filtration fraction is used. FF% = filtered volume divided by

volume of fluid entering the filter. If your ultrafiltrate is increased but not blood pump rate

(speed),theFF%willincreaseandmorelikelytoclotthefilter.

8. FF%iscalculatedaspredilutionflowrate+post-dilutionflowrate+fluidlossratedividedby

predilution flow rate+blood flow rate.Thepre-dilutionpump rateprogrammedaffects this

value(FF%).

9. Filtrationratio(FR)%:post-dilutionflowrate(ml/hr)+fluidloss(ml/hr)dividedbyBFR(ml/min)

X 100: So, FR% = UFR (ml/hr) divided by BFR (ml/hr) X 100. If FR is above 25%, haematocrit

increases,thereisahigherriskoffilterthrombosisandclot.TheFR%(keepunder25%)givesan

indication of haematocrit increases in the filter before the post-dilution solution replaces the

filtrate removed. This calculation is not affected by the rates programmed on the dialysate

pump.