Speeding Up Setup

[Restorer]

I feel like the whole process of setting up, putting myself on, doing the dialysis (with half-hour interruptions for stats), taking myself off, and teardown takes a huge investment of time and energy. When I agreed to try NxStage, I had hoped (and had been lead to believe by brochures) that it would only take a little bit more time and effort than CCPD did a few years ago, and that needling myself would get easier as I did it more.

It takes me 40 minutes to do the initial setup, up to recirculation (prime step 23.0), including putting EMLA cream on my fistula; hanging all the bags and connecting them to each other; drawing heparin; setting out all my syringes, 2x2s, and tape; and the first round of snap & tapping. Then I let it recirculate on its own for at least another 30 minutes, to work out all the dissolved air and microbubbles. While it's doing that I'm mostly free to relax, unless I have to break down boxes and take out the trash (once or twice a week).

When I'm ready to get on, it takes at least half an hour to do the second round of snap & tap, take my pre-treatment stats, wash my hands and fistula, do all the line connections, draw saline syringes, pick off my scabs, and put in my needles. Then I start dialysis, get it up to speed pretty quickly, and I have about 2:30 actually running on dialysis, with interruptions every 30 minutes to record stats.

Then taking myself off takes at least 20 minutes, including time to hold the sites (each on its own, 5 minutes for venous, 7-10 minutes arterial). Plus another 5 minutes to change connections to get the remainder of the dialysate draining and to do my post-treatment BP/temp/weight. Then 5+ minutes to tear everything out of the machine and get it into the trash.

That's more than four and a half hours each day, 5 days a week, with no span longer than half an hour without having to actively do something related to the session. It's taking a ridiculous chunk of my time and focus, way more than I had hoped - twice the active attention time of PD, and twice the total time of in-center dialysis, each week. Yes, I feel somewhat better than I did on in-center hemo, and PD is no longer an option for me, but it almost doesn't seem worth it.

 

In any case, my best option now seems to be to find some way to make home hemo faster and easier. I'm already setting everything up by memory. What things do you do to make set up, treatment, and teardown quicker and easier? Shortcut techniques? Clips, hooks, or clamps you added to help?

[Bill Peckham]

I find that after I let the machine cycle for a few minutes after the inital prime that clamping the arterial (red clamp) for a second or so does wonders for clearing micro bubbles.

With the 171 cartridge you can leave the red clamp closed for quite awhile but clamping for just a second or two makes snap and tap go much easier.

If I wasn't doing nocturnal I don't think I could stay on NxStage, a short daily schedule is a grind.

[obsidianom]

Why are you using bags? That is one reason it is taking so long. The Pureflow is SO MUCH easier and quicker to set up , use , and connect to. That alone will save you several minutes on both ends.  Also you really dont need so long after prime to snap an tap. I do it within a minute or two. Also see if you can just check vitals every hour during treatment if you are stable. We do that so treatment goes smoother. Every half hour is a pain in the butt.
I find the whole experience takes 3.5 hours per treatment for us with the actual time on machine of 2.75 hours.
Another option is going to 4 days per week , by upping the time and dialysate per treatment. There is a calculation for that . If you want to do that, have your nephrologist check the on line dosage calculater on NxStage and look at the numbers for you and see if it can work for you.

[amanda100wilson]

I changed tge settings on my machine to every hour so that I don't get tat interruption every thirty mins. I put my cartridge in ahead of time, and then snap and tap is much easier as there is less air to tap out.  Pureflow does make the process quicker.  The hassle of checking chloramines and changing thr SAK is much less than hanging bags.  When I pull my needles, I use Super Stoppers and tape them to hold pressure.  I do one site, and then with the Super Stopper holding pressure for me, I then pull the other.  I am fortunate that I never bleed much after so I up out of the chair within ten minutes.

[cattlekid]

I would agree with the previous posters regarding PureFlow vs. bags.  If you could make the switchover, I agree that you might find the process a bit less onerous.  Another thought is breaking it up.  I have read that several people set up their machine and let it prime in the morning, then turn it off when it gets to 23.  Turn it back on when you are ready, it will go through a short cycle then you can snap and tap and go. 

This next part might be controversial but it's my experience.  I never took more than 5-7 minutes to do two rounds of snap and tap.  I also never had a problem with air in the lines.  I think that some training nurses scare the bejeezus out of people with snap and tap and make it into something more than it needs to be.  I would set up my machine before dinner, let it prime, let it sit at 23 while I cooked, ate and cleaned up the kitchen, then a couple of rounds of snap and tap and I was good to go.

Another idea - do you make up kits for each treatment ahead of time with all of your supplies?  I know that would have made my life easier....10 minutes of rolling up a weeks worth of kits might have been easier than remembering to set out everything each day. 

I do know that it gets to be a grind though.  I worked full time and did 5 days a week and boy was it brutal especially when I had something going on both days on the weekend and had to do all five days on weeknights. 

[Restorer]

I'll be switching over to PureFlow... at some point. It was supposed to be this month, but there were delays? I don't know. It's still the plan to get me on the PureFlow, though, and that looks like it will at least save me from having to lift 3 bags over my head. The bags don't make anything take longer, because I set up the bags while the machine is priming, and I'm usually done with setting up the bags and drawing heparin before priming is done.

I really don't have a problem with the snap & tap. If I left it alone to recirculate for half an hour with no active snapping or tapping, I'm sure it'd get rid of most of the microbubbles on its own. But since I have to flip the dialyzer anyway, I tap my way through the arterial and saline lines, flip and tap the dialyzer, tap very quickly through the venous line (which by that point is usually clear already), and then leave it to circulate. When I come back to it, all the visible microbubbles in the lines are gone, and there's a good half-inch-tall air bubble in the dialyzer header, which I can easily tap out. If I leave it for another 10 minutes, a few more small bubbles accumulate.

The saline line is the only part that takes much time. I haven't even given myself saline recently, but just in case, I want to make sure it's clear too. Bumping up the Recirculation Fluid Pump setting (30) helped a lot with that.

I'd love to try nocturnal, but the only option for that with NxStage out here is a clinical trial in San Jose - not at all convenient.

[Angiepkd]

I am with you, Restorer!  Sometimes it feels like a full time job.  I do feel pretty good, though, so it is worth the effort.  I haven't found anything to speed up the set up or tear down.  It takes me about 4 1/2 hours from start to finish.  Hang in there! 

[obsidianom]

I find that after I let the machine cycle for a few minutes after the inital prime that clamping the arterial (red clamp) for a second or so does wonders for clearing micro bubbles.

With the 171 cartridge you can leave the red clamp closed for quite awhile but clamping for just a second or two makes snap and tap go much easier.

If I wasn't doing nocturnal I don't think I could stay on NxStage, a short daily schedule is a grind.

I tried the red clamp clamping you recommended. It worked GREAT. Thanks so much for that. I really didn't spend much time on the snap and tap but this really gets the bubbles out quickly. You should patent that.
I agree with others that we waste too much time worrying about snap and tap .I think 2 times with the red clamp clamped for a second or two gets out the bubbles. I also tap the filter rather aggressively on my hand .

[Simon Dog]

I noticed you use EMLA cream and also pick scabs.  Usually, once a buttonhole has matured to the point where you can use blunts, the cream is no longer needed.  I have no trouble sticking in blunts without the cream.

I use the BabyK on an every other day protocol.   With a full time job, the remainder of the day is shot on dialysis days- 4 hours in bed browsing the web, catching up in emails, answering arterial pressure alarms, and catching up on old TV series via Netflix.   It's a lot of work, but beats the crap out of in-center.

[Restorer]

I'd love to see data backing up your "usually" assertion. All of the buttonholes I've had have been very sensitive. My fistula is pretty thick-walled and on my upper arm.

I do feel better now that I'm not on the up-and-down roller coaster of in-center treatment. I do my dialysis in the evening, and I can concentrate in the mornings, which means I can work again. Even on my off-days, my concentration was affected when I was in-center, and dialysis days were almost entirely taken up by recovering from dialysis in the morning.

It's just that now I don't have much free time when I both have an appetite and am not exhausted. It's hard to squeeze cooking and eating in between work and dialysis. And if I'm not eating as much, I have even less energy... and it becomes a downward spiral.

[amanda100wilson]

The buttonholes don't hurt thing, doesn't apply to everyone and besides everyone's pain threshold is different.  As with everything, one size dies not fit all

[Simon Dog]

I'd love to see data backing up your "usually" assertion.

The only data I have is the word of the RN who trained me on the BabyK who told me to stop using the cream.     I have a rather shallow forearm fistula, so that may make it easier.

[Elly50]

Hi I also fiind the timing to long on Nstage, I used to be on 6 days a week for 2.5 ( though really it was 2.45 mins) now have been changed by the hospital to 3 hrs using 30 lt of fulid so more time changing the sac.
Dont feel as well and it is taking a huge part of the day around 4 hrs making life a misery and not what expected
Has anyone else had to stick to these times ?

[obsidianom]

The web based calculator can be used by your nephrologist to figure out how to change your settings to get better hours. For example an increse in the flow fraction can speed up the dialysate to get the 30 liters in much faster than current  time . The flow fraction can go quite high. The fastest dialysate rate is 12 liters per hour. With the machine at max, 30 liters would only take 2.5 hours. There are ways to do it easily including fewer days. Your nephrologist should go online to the calculator and plug in your numbers and show you the various optiions. there should be 4, 5, 6 day options and various times and speeds.

[Simon Dog]

Another option is a more conventional machine like the BabyK.    You can get more dialysis in during a run so schedules like 3x/wk or every other day become feasible (though evidence suggests every other day is better than 3x/week, the default for the big machines in 3x - unless you ask for eod or have an enlightened neph).

[Restorer]

The BabyK and other dialysis machines that require plumbing modifications aren't an option for me or plenty of other people. I live in a second-floor apartment. It may be a "reasonable accommodation" to do the work on the apartment to get a BabyK working here, but I maybe be moving within a year, and I've never really stayed anywhere long enough for something like that to make sense.

I'm not sure I see the point in doing a 3x/week schedule at home. The biggest reason I wanted to do home hemo was for better, more consistent treatment, hence the 5 treatments a week. If I'm going to be doing what's basically the same as in-center treatment, just at home, and I don't have the option to travel any easier, and I have to do all the setup, testing, and sterilizing myself, I don't see the benefit in that.

The only benefits seem to be a greater variability in dialysate composition (NxStage only has 3.0 Ca dialysate, for instance), and the ability to get more total dialysis (ignoring the fact that Medicare probably wouldn't pay for it).

[Bill Peckham]

The web based calculator can be used by your nephrologist to figure out how to change your settings to get better hours. For example an increse in the flow fraction can speed up the dialysate to get the 30 liters in much faster than current  time . The flow fraction can go quite high. The fastest dialysate rate is 12 liters per hour. With the machine at max, 30 liters would only take 2.5 hours. There are ways to do it easily including fewer days. Your nephrologist should go online to the calculator and plug in your numbers and show you the various optiions. there should be 4, 5, 6 day options and various times and speeds.

If you wanted to get the cycler up to 12 liters/hour you'd need to run a 500 blood pump speed. The way NxStage connected blood pump speed to dialysate speed has always been a weird quirk of the system. The issue for NxStage is the dialysate - their system limits dialysate so it is designed to make the most of each unit of dialysate. Machines like the Baby K have unlimited dialysate so they are designed to make the most out of unit of time. The complaints I hear are from people who value a unit of their time more than a unit of dialysate.

It is hard for me to not feel wistful for the Aksys PHD - if it could only come back to the market as a device that was reliable and had a business savvy tech support system, like NxStage's swap out approach, which is NxStage's key innovation. The Aksys had basically no set up time day to day, high clearances from fast dialysate pump speeds and hemodiafiltration, top of class biocompatibility, big high clearance artificial kidneys ... sigh.

[obsidianom]

The web based calculator can be used by your nephrologist to figure out how to change your settings to get better hours. For example an increse in the flow fraction can speed up the dialysate to get the 30 liters in much faster than current  time . The flow fraction can go quite high. The fastest dialysate rate is 12 liters per hour. With the machine at max, 30 liters would only take 2.5 hours. There are ways to do it easily including fewer days. Your nephrologist should go online to the calculator and plug in your numbers and show you the various optiions. there should be 4, 5, 6 day options and various times and speeds.

If you wanted to get the cycler up to 12 liters/hour you'd need to run a 500 blood pump speed. The way NxStage connected blood pump speed to dialysate speed has always been a weird quirk of the system. The issue for NxStage is the dialysate - their system limits dialysate so it is designed to make the most of each unit of dialysate. Machines like the Baby K have unlimited dialysate so they are designed to make the most out of unit of time. The complaints I hear are from people who value a unit of their time more than a unit of dialysate.

It is hard for me to not feel wistful for the Aksys PHD - if it could only come back to the market as a device that was reliable and had a business savvy tech support system, like NxStage's swap out approach, which is NxStage's key innovation. The Aksys had basically no set up time day to day, high clearances from fast dialysate pump speeds and hemodiafiltration, top of class biocompatibility, big high clearance artificial kidneys ... sigh.

I respectfully disagree with the blood speed of 500 .  12liters per hour is 200ml per min dialysate.   If you set your flow fraction to 50% , the blood speed would be 400.
If you set the flow fraction to 100% the blood speed would be 200. You can set the flow fraction to what works for you on the backround settings. A flow fraction of 75% would give a blood speed of 267.  A flow fraction of 60% would give a blood speed of 333 which is reasonable.
There are nunerous combinations that can be done using the default flow fraction setting when the machine is off in the backround settings. Then you can easily do 12 liters per hour. I do 9 liters per hour for 25 liters easily. My flow fraction is around 43% and blood speed is 350.
I had the advantage of using the calculator on line as a doctor and ran various sample stats to see whatr the machine could do. I also talked to the techs a lot on the phone to question the system settings. Also Hemo doc helped a lot.He pointed out to me that Nxstage can run fast dialysate that begins to approach regular dialysis as the flow fraction can be quite high up to the limit of 200ml per min allowance for dialysate speed. Conventional dialysis is about 600 ml per min. so it is about a third as fast.

Bottom line is there are all kinds of ways to shorten the time on the machine by using the flow fraction setting and the volume of dialysate even with a fairly low blood speed of say, 340 t0 350. Check with your nephrologist and have him/her run sample numbers on the on line calcualtor for you to look at.
We used it and found my wife needed 5 more liters of dailysate than she was getting per traetment . Since we increased it she feels much better. It worked well for us to calculate what she needed  . Her kv/t was good so the nephro thought she was ok where we were , but she didnt feel right. So i ran the numbers on Nxstage calculator and found they recommended 5 more liters  and a higher flow fraction . So I have faith in their calcultor as being very good at figuring what works on their system.

[Simon Dog]

I'm not sure I see the point in doing a 3x/week schedule at home. The biggest reason I wanted to do home hemo was for better, more consistent treatment, hence the 5 treatments a week. If I'm going to be doing what's basically the same as in-center treatment, just at home, and I don't have the option to travel any easier, and I have to do all the setup, testing, and sterilizing myself, I don't see the benefit in that.

One of the reasons I went in-home was to get EOD instead of 3x.   I'll complete the journey in improvement in treatment when I get cleared for nocturnal.

As to setup - It takes me only a small bit more time in setup that it did driving to/from the clinic.

Another huge advantage is being able to have any particular day off.  I needed a Thursday off this week and was scheduled for D.  Instead of going from Fri-Sun-Tues-Thurs, I did Fri-Sat-Mon-Wed.   Shifting the cycle by doing treatments two days in a row gives me great flexibility, and assures I will not dialyze on my birthday or my wife's birthday.  Dialyzing on my anniversary is still up for debate.

Another benefit of self care is doing my own canulation, and not negotiating with techs about how much fluid to take off.

[moodyc]

Also, when you are on the machine, and it has an alarm, it adds your treatment time to the number of alarms and the time it takes you to clear them.  Ours is supposed to be 4 hours, but when I push the green kidney button, it automatically adds 12 minutes to my husband's treatment time.  At the end of treatment, I always lay out everything needed for the next day.  That saves time. It takes me about 5 minutes to do snap and tap.  I've read where the majority of the alarms are caused by the operator, but I have to disagree.  We go "by the book" and still  have alarms. Very frustrating.

[kyshiag]

I got the bags pictured in the attachment.  They come with white or red handles and can hang in a closet.  When he cooperates, my husband can make these ups for the week or longer.  The larger bags are used for getting on the machine and we use the smaller ones for getting off.  All supplies are placed in the bag and the red handled bags are only used when we have to take blood that day.  Its easier to just grab a bag and go rather then cherry picking items from all over the room.  It also helps him know a few days ahead if he is running out.  Still take a God-awful amount of time, though.

[obsidianom]

We use a stainless steel commercial kitchen cart. It has 3 layers and is on rollers. It sits next to our dialysis machine. I keep all our supplies on it except the cartridges and saks. It allows me to grab what I need quickly and can roll it around as needed. It makes everything so much easier.

[Speedy1wrc]

I've been searching for a post like this thank you all.

You see I am having a horrible time with getting rid of air too.It literally takes hours. I let it go through prime, but unless I wait at least an hour idling the bubbles are horrendous. I know why and it's a temperature issue with the de-gassing. In the Northeast my house is at 68deg. The machine is 85deg. When all 3 pumps run at full speed at 2.1 they saturate the saline and it de-gasses as the temp of the saline rises. Depending on the ambient temp will dictate how bad or if this will even happen.

So here's the deal.NxStage says that no one has ever complained about this before. BS, I've been complaining about it to them for over a year. I spoke with someone there a year ago and now according to them it never happened. I pushed them on it and they did admit that it actually does happen, but not often. Funny how a year ago they knew all about it. I am fighting an up hill battle for them to first acknowledge it and then fix it. They are stonewalling big time.

If anyone is seeing air that goes away with time and waiting please call NxStage and ask to talk to Peter. Do not let him dismiss you and hold his feet to the fire to fix this. I am frustrated as you are that treatment takes so long. I need to do treatments in the morning and don't feel that I should have to get up at 4am to be on by 7am. Yesterday and today it took all day. Today I started prime at 9:30am and I came off at 4:30pm. Not acceptable.

Whenever you have issues, please call NxStage even just as a second thought. In our area patients have been having issues with defective cartridges also. But when I and the home memo nurse call in, NxStage says they never see any other issues. Please report any and all issues so they can be fixed.

Thanks in advance,
Mark

[obsidianom]

I've been searching for a post like this thank you all.

You see I am having a horrible time with getting rid of air too.It literally takes hours. I let it go through prime, but unless I wait at least an hour idling the bubbles are horrendous. I know why and it's a temperature issue with the de-gassing. In the Northeast my house is at 68deg. The machine is 85deg. When all 3 pumps run at full speed at 2.1 they saturate the saline and it de-gasses as the temp of the saline rises. Depending on the ambient temp will dictate how bad or if this will even happen.

So here's the deal.NxStage says that no one has ever complained about this before. BS, I've been complaining about it to them for over a year. I spoke with someone there a year ago and now according to them it never happened. I pushed them on it and they did admit that it actually does happen, but not often. Funny how a year ago they knew all about it. I am fighting an up hill battle for them to first acknowledge it and then fix it. They are stonewalling big time.

If anyone is seeing air that goes away with time and waiting please call NxStage and ask to talk to Peter. Do not let him dismiss you and hold his feet to the fire to fix this. I am frustrated as you are that treatment takes so long. I need to do treatments in the morning and don't feel that I should have to get up at 4am to be on by 7am. Yesterday and today it took all day. Today I started prime at 9:30am and I came off at 4:30pm. Not acceptable.

Whenever you have issues, please call NxStage even just as a second thought. In our area patients have been having issues with defective cartridges also. But when I and the home memo nurse call in, NxStage says they never see any other issues. Please report any and all issues so they can be fixed.

Thanks in advance,
Mark

I also live in the very cold far norhtern areas. It was well below zero last night. I keep my house cold.
Now some advice. I take out a cartridge and saline bag the day before treatment and put it near a warm area in my house so it warms up. I keep my supplies in a cold area normally. So the saline is a bit warmer before use as is the cartridge. I do the same for a sak .
When priming the cartridge, when it gets to the "23" and is ready to snap and tap, I let it sit for about 15 minutes . Then after my first snap and tap cycle, I clamp the red clamp for a few seconds to let the air bubble up. Then I release it and it forces the air in all the lines out. I do this two or three times in a row. Then I finish my snap and tap. I never have air alarms now. 

[Restorer]

You see I am having a horrible time with getting rid of air too.It literally takes hours. I let it go through prime, but unless I wait at least an hour idling the bubbles are horrendous. I know why and it's a temperature issue with the de-gassing. In the Northeast my house is at 68deg. The machine is 85deg. When all 3 pumps run at full speed at 2.1 they saturate the saline and it de-gasses as the temp of the saline rises. Depending on the ambient temp will dictate how bad or if this will even happen.

...

If anyone is seeing air that goes away with time and waiting please call NxStage and ask to talk to Peter. Do not let him dismiss you and hold his feet to the fire to fix this. I am frustrated as you are that treatment takes so long. I need to do treatments in the morning and don't feel that I should have to get up at 4am to be on by 7am. Yesterday and today it took all day. Today I started prime at 9:30am and I came off at 4:30pm. Not acceptable.

What brand of saline do you use? I've noticed more bubbles sticking to the sides of the bag when I use Baxter saline than when I use Fresenius saline, but I don't think I've noticed a difference in the bubbles in the lines. But then, I have the time to let it prime for a full hour to work out the bubbles.

Try the clamp trick described above. It works wonders for me. I tap out the bubbles at the top of the arterial line, clamp the small red clamp for about a second then unclamp it, let it circulate for 10 seconds or so, then clamp it for 3 or 4 seconds, and unclamp again. It clears that line quite well initially. The bubbles do build back up as the saline warms, but they clear just as easily with another clamp-unclamp. I also do the same to the saline line by kinking it and holding it tight for 5 seconds or more, then pulling it straight quickly to flush the bubbles out.

What about priming the machine the night before, shutting it off, and then turning it back on in the morning? If you have enough time to let it warm up and outgas at night, then clear it, you won't have any problems in the morning. If you don't have the time at night to let it circulate for an hour, you can clear the initial bubbles and shut it down, start it up the next morning once it's settled, and stop the recirculation before the saline warms too much.

If all else fails, you can prewarm the saline bag (still inside the outer wrapper) on a heating pad on low overnight, or (most nurses will say this is a no-no, but it was unofficially "okay" when warm PD solution was needed quickly) you can carefully microwave the saline in 20-second intervals, mixing it by squishing the bag between cycles, until it's warm. If you bring it near body temp, it will only cool when circulating, and will absorb tiny bubbles instead of releasing them. (Also you won't get that unpleasant 30-60 seconds of cold saline and blood at the start.)