TIPS, TROUBLESHOOTING AND LESSONS LEARNED

SETUP
-Preparation
-Priming
-Dearation level
-Starting treatment

ONGOING MANAGEMENT
-Preparation
-Priming
-Dearation level

 

 

 

 

SETUP IN CCTC

PREPARATION

  • Before removing the set from the package, check all luer lock connections to ensure they are tight. In particular, check the access and return connections, the connections to all spikes and the connections at the dearation filter. Connections are loosely connected to facilitate gas sterilization.
  • Prepare solutions. Remember to add KCl to dialysate per protocol. If dialysate is not being administered, KCl should be ordered to replacement solutions per protocol.
    • Standard CCTC Setup:
      • Predilution replacement administered via Pre Blood Pump (PBP)
      • Replacement pump programmed to deliver POST DILUTION replacement (usually at 200 ml/hr) to prevent clotting in the dearation chamber
    • Citrate Administration Only
      • Administer citrate via PBP
      • Administer all replacement fluid (e.g., 1000 ml/hr) POST DILUTION via replacement pump.
  • Always turn the machine "OFF", then back "ON" before setting up a new filter (even if you restarting the same patient). This will ensure you have cleared any alarms from the previous run.
  • Do not turn the heater on until after the circuit is connected to the patient and the heater tubing is filled with blood. When bicarbonate containing solutions are heated, CO2 gas is produced, increasing the number of bubbles.

SET PREPARATION

  • Always setup in "CVVHDF" mode.
  • Remember to connect the heater tubing.
    • Position the green marking on the heater tubing at the front of the heater and wrap from front to back.
    • Pull and stretch the tubing during positioning to reduce the chance of kinking when the cover is replaced.
    • Have a second person assist you as you open up the blue connection in the return tubing (below and to the left of the dearation chamber) and connect the heater tubing. There is only one way the heater tubing can be connected (male to female). It is normal for the return tubing to cross behind the filter and again underneath the heater.

PRIMING

  • Be sure that the connections are tight, especially at the return protector (the filter above the dearation chamber), the access and return connections, and the luer lock connection on the spike inserted into the prime collection bag.
  • Priming with a filter of 150 or higher will required 2 bags of priming solution (smaller filters such as 100 and 60 only require a single bag). 
  • In a two bag prime (usual for ST 150):
    • The "ST" stands for surface treated. Surface treating makes heparin adsorb (adhere) to the filter surface.
    • Tthe first bag usually has 5,000 units of heparin added per liter, unless there is an absolute heparin contraindication (e.g., HITT).
    • The second priming bag is 1 L of plain normal saline. At the onset of therapy, the patient does not receive a bolus of heparin if the second bag was heparin free.
    • In small size filters (used in paediatrics), only 1 L of priming solution is required. If that liter contains heparin, the patient will receive roughly 150 - 180 ml of heparinized saline at the onset of the treatment unless additional priming is done.
  • If heparin is not being administered, prepare a 20 ml syringe with a LUER LOCK connection with 0.9 NaCl and install into the syringe pump.
  • Hang a bag of normal saline on any pump that is not being used (e.g., if dialysate had not been ordered, hang saline on the dialysate pump during priming and set the dialysate flow rate at "0".
  • In the last minute of priming, you can gently flick or wiggle the loop in the heater tubing to faciliate removal of air bubbles. Small air bubbles do not need to be removed.
  • It is normal to have air in the effluent pod or a few inches of air in the effluent tubing. You DO NOT need to prime a second time; this air will be eliminated during the Prime Test.
  • Air bubbles in the blood side will be collected in the dearation chamber.
  • At the end of priming, check the dearation chamber and adjust the level if required.
    • Following priming, an air pocket will sometimes collect in the dearation chamber below the mesh filter, displacing fluid into the tubing above the dearation chamber.
    • Ensure that the
    • Always check the dearation chamber carefully; it can be difficult to differentiate fluid from air.
    • If fluid has risen into the tubing above the chamber, lower the fluid level by choosing "adjust level", and using the DOWN arrows to drop the fluid level below the dearation chamber. After the level is dropped, select the UP arrows and move the fluid level to the desired location.
    • It can be difficult to differentiate fluid from air. Dropping the level , appearing as though fluid is in the chamber.
    • DO NOT do any additional priming without hanging a second bag of priming solution or the bag will run dry during the prime test (the prime test using the remaining 150 ml of the 1 Litre bag of solution).

CONNECTING TO PATIENT

At the end of priming, select "continue" and enter flow rates prior to connecting the circuit to the patient.

Initate treatment with fluid removal set at "0" and blood flow rate at 150 ml/min.

Prior to connecting the circuit to the patient, switch the blue return line and the effluent line. (The effluent line should be moved to the effluent bag, and the return line should be moved to the "Y" connector on the priming "Y". Clamp the access and return lines and move the priming bag close to the patient's access site to facilitate connection.

Disconnect the access tubing from the "Y" connector and add a 3-way stopcock. Prime a regular IV tubing set with normal saline and connect to the stopcock.

Prepare the limbs (check for clots with a 3 cc syringe and flush with saline).

Instill the heparin bolus (if ordered) into the access limb and connect the stopcock at the end of the access line to the access limb.

Conect the return line to the return limb (blue to blue).

YOU MUST CONNECT THE PATIENT WITHIN 30 minute of priming. If more than 10 minutes elapses, repriming must be performed again.

 

 

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References:
Gambro Training Manual 1 and 2
Slides from Gambro Training package, reproduced with permission

Last Update: March 30, 2010, April 8, 2016

Reviewed: January 30, 2015.

 

LHSCHealth Professionals

Last Updated April 8, 2016 | © 2007, LHSC, London Ontario Canada