SAK leaks

[Vt Big Rig]

With about 30 minutes to go last night we get a 14 alarm. Happened once during training and the nurse showed us to open the tub and gently shake the SAK. Some lines might be caught under the SAK. Slide out the tub and there is about an inch of dialysate in it. No leak alarm. And then it goes off. Stop treatment , rinse back, bail out the tub, dry it with towels and a hair dryer and can't get the alarm to stop. Wipe endlessly with a paper towel around detector. Tech support has us shutoff machine and unplug J2 line and start over. That seemed to have worked. Did not go off again all night and a new batch is made for tonight. First SAK problem we have had (but only running 3 months).

Of course it was lab day so we did not get a full treatment in .....

But I must say tech support is calming when they walk you through every thing.

[Vt Big Rig]

AND ANOTHER SAK PROBLEM

My wife wakes me up at 4AM because the Pure Flow is in alarm. It says conductivity test failed and we have a small puddle of water on the floor in front of the pure flow. (We have it up on a small dolly). We follow the instructions to retest the conductivity and I mop up the fluid with some paper towels. While waiting the 15 minutes or so for the test I notice a drip off the bottom of the loop of the water inlet to the SAK. (the line with the blue clamps). It looks like the micron in line filter has a small crack in it. So I call Next Stage and ask if I can clamp the blue clamps and still be able to run today. They say yes. The machine moves on to the "Check Chloramines" screen. Good right?

As I am lying on bed I think I better check the chloramines just to be sure. As I try that, when I am waiting for it to dispense, I get a alarms for output pressure. So I open the blue clamps and try again. It dispenses and I closed the blue again. They pass. But now I am nervous that during the run tonight I will get some other alarm.

I read several posts about trouble with Pure Flow and I had never had any. Now.... two leaks in three days!

[Simon Dog]

I've been on NxStage for 16 months, and in that time, I've had three incidents where the micron filter leaked at the weld between the two halves.    NxStage responds by sending a UPS call tag out for the failed SAK.

You'd think they could get better reliability in something so simple.

[Vt Big Rig]

I've been on NxStage for 16 months, and in that time, I've had three incidents where the micron filter leaked at the weld between the two halves.    NxStage responds by sending a UPS call tag out for the failed SAK.

You'd think they could get better reliability in something so simple.

That appears where this leak is ......They did not say anything about sending a UPS truck. And do you recall if you where able to run with blue clamps closed.

[Simon Dog]

I never tried running with the blue clamps closed, but I know they need to be opened when you flush at the end of the SAK drain.

If you call NxStage and report a "defective SAK", they will send a UPS driver with a return label.  Takes about a week.

[PrimeTimer]

Another area to check is the Conductivity Sensor Connector (orange circle on the PureFlow Control Unit). I didn't have a leak but one time while changing the orange SAK line, a slow steady drip of water came out the orange connector on the control unit. Enough where I had to use some paper towels to mop it up and hold some paper towels over it until I screwed on a new SAK line (the line with the orange clamp on it). Talked to NxStage about it and they had me put on one of those spare PureFlow SL Control Unit Conductivity Sensor Adapter's (they come in a little clear plastic bag taped to the side of every new PAK) and leave it on and use that each time I make a new SAK. I change out the adapter line about every other time that I prime a new PAK.

This may not be your problem but if water is dripping down from orange connector on the control unit, it might drip down and make it appear that the source of the leak is something else.

[Vt Big Rig]

I never tried running with the blue clamps closed, but I know they need to be opened when you flush at the end of the SAK drain.

If you call NxStage and report a "defective SAK", they will send a UPS driver with a return label.  Takes about a week.

That worked. We got the run in and opened the clamps when we got to flushing. It leaked again but flushing is not for long.

I did notice I got to "00" in about 15 seconds after 4 minutes was showing and numbers said 39.2 liters of dialysate ( I am set for 40 liters) so maybe the leak caused a small shortage there.

Thanks for the help.

[Vt Big Rig]

OK, we tried this lot 6 times and had three failures    ........... this time it is leaking from the micron filter(s) in the dialysate supply line. (Green clamps).

Finally NextStage agrees to send me more and a return OK to ship this junk back. Watch out for SAK 405 lot 50279080

[Simon Dog]

OK, we tried this lot 6 times and had three failures    ........... this time it is leaking from the micron filter(s) in the dialysate supply line. (Green clamps).

Finally NextStage agrees to send me more and a return OK to ship this junk back. Watch out for SAK 405 lot 50279080

What flow rate do you run the dialysate at?   Just curious, because I see you are using the SAK for the high (>12L/hr) flow rate but have a modest volume (40L) in your Rx.

[Vt Big Rig]

What flow rate do you run the dialysate at?   Just curious, because I see you are using the SAK for the high (>12L/hr) flow rate but have a modest volume (40L) in your Rx.

I think it depends on fluid we are taking off. This second I am at 12.9 l/hr, 0.55 l/hr, 450 ml/min blood flow, taking off 1.1 liters. time is about 3:08 hours/mins.

[obsidianom]

What flow rate do you run the dialysate at?   Just curious, because I see you are using the SAK for the high (>12L/hr) flow rate but have a modest volume (40L) in your Rx.

I think it depends on fluid we are taking off. This second I am at 12.9 l/hr, 0.55 l/hr, 450 ml/min blood flow, taking off 1.1 liters. time is about 3:08 hours/mins.

Your blood flow rate is WAY too high. There is never a reason t go over 350 or so.   You gain nothing  on Nxstage with higher blood flow rates.  High flow rates stun the heart and damage the fistula . Remember the famous words of the esteemed nephrologist Dr. Agar ,   "please don't flog the fistula." . This is in regards to fast blood flow  rates over 350.

[Vt Big Rig]

Your blood flow rate is WAY too high. There is never a reason t go over 350 or so.   You gain nothing  on Nxstage with higher blood flow rates.  High flow rates stun the heart and damage the fistula . Remember the famous words of the esteemed nephrologist Dr. Agar ,   "please don't flog the fistula." . This is in regards to fast blood flow  rates over 350.
[/quote]

What can I say, that is what we were trained at. Can you give me a link to information on "flog the fistula"? I am perfectly willing to argue with the neph if armed.

[obsidianom]

 DONT FLOG THE FISTULA----PLEASE!!!!
« on: March 15, 2014, 09:26:14 AM »

Check out this thread from March 14 to 18, 2014 in general Discussion area.  You can also look up Dr Agar and his writings about this on Home Dialyzers Network . he writes about this extensively. 

[obsidianom]

Here is the article from Dr Agar  ." Don't flog the fistulas: Slow hemodialysis blood flow!"


The use of excessively high blood flow rates (read "pump speed") during dialysis—flow rates of upwards of 350 ml/minute—appears to be a US-only phenomenon (read "tragedy"). They are symptomatic of the short-hour dialysis epidemic that is also a US-only phenomenon.

When will US nephrologists learn?

The mean blood flow rate in the US (DOPPS 2011) is ~450 ml/min. The mean blood flow rate in Australia and New Zealand is ~300 ml/min (~36% less). Blood flow rates in Australia and New Zealand are similar to those used throughout Europe, and both are still greater than flow rates used in Japan. Patient session times in the US are also markedly shorter than in any other country. And, patient survival in the US is dramatically less than in any other country—yet patient age, incidence/prevalence of diabetes, and cardiovascular morbidity is no different.

The flawed logic of US dialysis, driven as it is by the twin forces of profit and through-put, is that short, and commonly also infrequent dialysis is somehow "OK." Well, it is not OK. The misguided view that shorter treatment times—only possible if blood flow rates are screwed way up in an attempt to achieve the CMS-approved Kt/V (also a flawed and discredited measure of dialysis) are somehow 'acceptable', is a fallacy that has benighted US dialysis for more than two decades.

Speaker after speaker at the recent Annual Dialysis Conference in Atlanta (February 8th - 11th 2013)—myself included, in all of my four separate addresses to the conference, including the conference-opening Keynote speech—pleaded for longer, more frequent and gentler dialysis regimens.

Speaker after speaker emphasised the benefits of slower blood flow rates and longer dialysis time on patient symptomatology (nausea and vomiting, cramp induction, in-treatment hypotension, post-treatment recovery time), on middle molecular clearance from deep compartmental tissues (Eloot)1, on prevention of myocardial and other organ 'stunning' that accompanies rapid volume contraction (McIntyre), and on quality of life and survival.

Nephrologists who do not understand the simple principles and widely documented advantages of slower volume removal and better solute clearance that accompany longer time on dialysis simply do not understand the first principles of dialysis.

They might do well to read the literature that confirms these unassailable dialysis facts. They might do well to hear the message—a message given and shared by every dialysis expert—that the only...repeat ONLY...determinant of good dialysis, of a well patient, and of a long-surviving patient, is the time spent each week on dialysis: the weekly membrane contact time.2

They are the poorer if they have not read and understood the potent message about 'time and frequency' left to us by Belding Scribner and Dimitri Oreopoulos3 – the two regarded widely as the 'fathers of modern maintenance dialysis' ('Scrib' for HD and Dimitri for PD). This meaasge was contained in their lightning-rod 2002 paper: The Hemodialysis Product (HDP): A Better Index of Dialysis Adequacy than Kt/V.3

They might even do well to attend the next ADC.

It is self-evident and has been long understood that the NCDS study, the study that spawned the iniquitous concept of Kt/V, got it badly (and sadly) wrong. It was not 'K' that mattered...it was 't'. Boosting K, by employing an ever faster and more furious pump speed to allow the contraction of 't', is incorrect. It kills people! Increasing 't' and, in the process, allowing the speed and ferocity of the dialysis process to be dialled back, saves people. It saves well-being as well as lives.

On a different but parallel plane, the December 2013 issue of CJASN featured a special section on fistula flow and flow dynamics. It emphasised the many causes of turbulence that accompany venous limb endothelial damage and in-fistula stenosis. One of these is the interruption and/or disruption of normal vascular laminar flow that occurs when the venous needle return jets into and against the venous endothelium at the site of venous return, creating physical turbulence and biochemical excitation of nitric oxide production...factors intimately associated with up-stream in-vessel stenosis.

At a symptom level, short dialysis treatments are symptom-rich; long treatments are symptom-free. Shorter treatments induce ever more cramp, hypotension, and misery. The shorter the treatment, the more comes the complaint: "I can't take this anymore" ...and the louder the pleas to "take me off".

Just think about it ...
•The shorter the treatment, the faster the removal of fluid must be to attain "dry weight".
•The faster the fluid removal, the more there is a risk of hypotension.
•The greater the risk of hypotension, the more likely is the need for saline resuscitation.
•The more saline that is given, the greater the counterproductive re-infusion of salt and water—and isn't this exactly what the dialysis process has been intent on removing?
•The greater the rate of contraction of the circulating blood volume, the greater the dimension of organ "stun"...and this affects more than just the heart!
•Residual renal function plummets as repeated acute kidney injury results from renal ischaemia.
•Cerebral function suffers from repeated hypo-perfusive cerebral injury.

The list is endless, yet somehow, the ignorance goes on. Yet, the cure is so simple that is beggars description that it has been so long ignored. Gentleness...respect for our patients and their physiology, and, above all, time.

Speaker after speaker at the ADC said it. Speaker after speaker pleaded.

Slow it down, America.

References:
1.Eloot S, Vanholder R, Van Biesen W. Dialysis duration: the longer the better, but why