bad rinsebacks

[Adam_W]

I just got the worst rinseback I've ever had since starting NxStage. I've usually been having better rinsebacks since I started putting my heparin in the venous line (I was trained to put it in the arterial line), but the last few treatments I've been getting progressively worse rinsebacks. I'm on 10,000 units of EPO/week, and my hgb is still on the low side. The lot# for these cartridges is #7067713. I've also been getting a lot more cartridges with badly kinked lines. These problems are just frustrating me so much that I've caught myself picturing a 2008K where my NxStage is now. I don't want to give up NxStage, but I also have to have reliable and safe equipment. Here is a picture of the dialyzer after rinseback.

Adam

[jbeany]

Adam, the tubing looks clear - is it just the filter end that worries you?  That one does look a bit red to me.  I was told when that sort of problem occurred that I needed to consider increasing the heparin dose.  How long are you running?  If it's a longer session, you might want to consider increasing the hep.  My nurse gave me the leeway to up the dose for any session where I had a lot of fluid on and planned to run longer than my usual 2 to 2-1/2 hours.  You can also up the rinseback, of course, but it looks to me like the problem might be more of excess clotting in the filter than a problem with the amount of fluid you are using during rinseback.

I was trained to put the hep in the venous line from the beginning.

[silverhead]

After all our problems with leaking cartridges, we received a new batch of 7077709's and today was the first use of one of them, opened the bottom of the box and sure enough - kinked lines, they were usable, but sure had me wondering, but pressures seemed ok throughout the run, on rinseback I observed the same thing you experienced, clotting in the outlet end, that is the first we have seen this in our 1 month at home. going to be watching this carefully after this incident......

[BigSky]

Its not really uncommon to see headers get like that from time to time, that really isnt too much.  If you start getting dialyzers with large sections of the fibers all red through them then that is something to be concerned about.   From the looks of your filter it looks ok and is pretty normal considering.

[Zach]

I've usually been having better rinsebacks since I started putting my heparin in the venous line (I was trained to put it in the arterial line), but the last few treatments I've been getting progressively worse rinsebacks.

Heparin is injected into the arterial line, so it hits the filter first, and therefore cuts down on clotting.  Using the venous line for Heparin injection means it goes into you first and the filter last.

I'm with BigSky for the rest.
 

[Adam_W]

Until now the header has usually been completely clear. I've also been getting more streaking in the dialyzer, and blood flowing back out of the dialyzer into the arterial line after the pump is stopped. I know it could be worse, but I know it could be a lot better as well.

Adam

[Black]

That filter end is not much different what we usually see, and it is not unusual to see Mike's darker than that.  We've never had one clot but occasionally have seen quit a few red lines in the filter.  We also occasionally see some minor clotting in the pressure pod - usually when he has been outdoors sweating a lot and hasn't had enough to drink to make up for the sweating.  Since he is now running 15 minutes longer we may need to up the Heparin a little, but good so far.  Anyway, I see no reason for concern if that is as bad as yours gets because the lines were still clear.

We ALWAYS put the heparin in the venous line so it goes into him and mixes with his blood BEFORE it hits the machine, which filters out heparin.

BTW, I got a list of the bad cartridge lot numbers from our dialysis nurse which I will be posting in another thread.

[Russ]

Increasing hep worked for me when I had this problem in the past.

[charee]

Increasing hep worked for me when I had this problem in the past.

just curious how much heparin do you all use ?

[jbeany]

NxStage is a bit different with the hep - there's no pump, so you have to get it all in one dose at the beginning.  I'm on 3000 cc's.

[Adam_W]

I've just gone from 3000 to 4000. Since I've started putting in 4000, I've had near perfect rinsebacks, except for two (the one I mentioned here and the next day). I just got off the machine today, and I had a clear rinseback, still using 4000 of heparin. With these 170 dialyzers, it seems to be kind of hit and miss.

Adam

[charee]

NxStage is a bit different with the hep - there's no pump, so you have to get it all in one dose at the beginning.  I'm on 3000 cc's.

Thanks for that , Jbeany i didn't know that.

[Russ]

Increasing hep worked for me when I had this problem in the past.

just curious how much heparin do you all use ?

I'm on 8000 hep but I'm a big guy.  I also take an 81mg aspirin per day.  I hold for 15 minutes after tx.

[Black]

just curious how much heparin do you all use ?

Mike started 2/5/07 at 3,500 units.  In just a few days we found that wasn't enough, got clotting alarms on the NxStage, and so we raised to 4,000.

This past week he increased the dialysate to 25 from 22.5, the time went up about 15 minutes, so we had to raise the Heparin to 4,500 units.  Today, after we pulled the needles, his arterial access clotted in 6 minutes so we may have to go to 5,000.  I am apprehensive about going up too much because he now bruises so easily.  Gross looking blotches on his other arm from doing some work with tools earlier in the week.    Also, he may have been slightly dehydrated -- so we'll continue at 4,500 for a few more times and keep checking his clot times.   BTW, he's a big guy -- today his end weight was 123.7.

[jbeany]

Oh, yeah, the bruising is continual, isn't it?  People keep pointing at the big bruises on my arms and legs and asking me what happened.  Most of the time, I have no idea. 

[cev]

Hi
We do not always have real good rinsebacks either, when I don't think his lines are clear enough I just run an additional amount (our rinse back is set at 252, after the rinseback if you hit rinseback again you can do more, just watch the count down so you know how much more you have to use. 

Also if it is a continuing problem you can check with your nurse and set the machine to automatically do more rinseback. 

We try to keep Richard's dry wt at 92.0 and I have increased his heparin to 7000 bolus in the arterial line.

Bruising is a problem and I would advise checking with your doctor, according to Richard's MD the heparin is shortlived and should be out of your system in 2-3 hours.  If your are on coumidin (sp) then for sure check with doctor, it could be very dangerous.

We also received some of the "new" filters and are finding badly kinked lines.  Overall they do seem to be better then the 1st batch of "new and improved"

[cev]

Hi Adam,
since you posted and I said we were still getting good rinsebacks, I have been paying more attention to the lines after the machine has set - and yes there is a lot more blood that has drained from the filter after the rinseback then the 160s.  I will let our nurse know, with his anemic condition I have to try to get every little drop back to him. Thanks for bringing this up.

[skyedogrocks]

Too much Epo can cause some clotting in the filters and bad rinsebacks.  Rob's hemo was so low they increased his epo and put him on Venipher (iron) in a month his hemo was a bit too high, so they took him off Epo and kept him on Venipher.  However, the rinsebacks are just starting to look alot better.  His nurse told us it was too much hemo and Epo.