Clotting

[Hootie]

We had a challenge yesterday in treatment. Recently in most treatments, we have taken the UF rate down to .7 based on blood pressure dropping after one hour at 1.0 rate of UF. Clinic advised us in training that a general rule...if you take of a UF volume of 2.0 or more use a rate of 1.0. If less than volume of 2.0 use .5 UF rate. Reading Dr Ager's work it states that the top rate should be .7 to have a better probability of the blood pressure not dropping until very end. If we use 1.0 UF rate it drops at one hour. If we use .7 we get usually two hours. In both cases we drop the UF rate to .3 or .4 and give a small bolus, if pressure has dropped to 95/x or lower. If blood pressure comes back up the we raise the UF rate back up slightly to minimize time on machine. That has been our standard procedure during the last month or so. It causes us to be on machine longer but minimizes any BP issues at end.  Used to we could do 1.0 rate for two hours without dropping and get of at 2:26-2:30. That is using 25 liters and taking off a little over 2.0 or taking off 1.3 and taking off rate of  .5 UF. Have also been struggling to get to dry weight as my replacement machine is still having trouble taking off amount it says it is taking off. Usually .3-.5 liters light.

Here is the challenge yesterday...at the 3:04 mark....with arterial and veinous pressure all perfect...i.e art 165 and veinous 175.....all of sudden the red 10 alarm went off....only had it one time before and I saw no air so I stopped and restarted the machine immediately. It went for  few seconds and then the red 30 alarm went off...i got NxStage on phone in about 30 seconds. By then the veinous had sky rocketed to cause the red 30. They asked about clotted and I examined that the blood was darker red and splotchy. NxStage advised to terminate treatment immediately and no rinse back. They also advised to call nurse and let her know that we lost 190cc of blood with no rinse back. NxStage and nurse really did not have a reason that the clotted happened so quickly. Both said had to get air in from somewhere. The tubes from machine were clotted in end and when I went to pull needles...big changes in color and clotted was evident in fistula needles. I never saw any air in the tubes or dialysate and we were well into treatment. Blood pump speed 385 and dropped to 350 at first sign of problem.

The only anomaly that we saw was the arterial needle had pushed out a fair amount but there was no bleeding around it and the arterial pressures were perfect. Veinous needle was where I put it originally.

For the veterans, who have been doing this for some time, what are your thoughts on cause and prevention? Been doing it since January 2015 and have never had a clotting issue.

[hatedialysis2]

I've been on nxstage since 2013.  Don't consider myself a veteran expert so I hope I can answer your question. 

First, clotting will occur if you take more than 2 minutes to resolve a red alarm.  I would recommend two things.  1.  keep a copy of the  major alarms (air/pressure). Along with probable cause and  actions to resolve  by your chair.   2.  Whenever you get a red alarm call nxstage right away to walk you thru if you are dealing with an alarm yogurt used to.   

According to my Manuel, aAn alarm 10 (Venus air). Occurs when
1.  Air is entering the blood circuit
2. Arterial connection loose (between patient and blood pump)
3. Arterial access dislodged or disconnected
4.  Air in saline for priming , bolus, rinsback
5.  Residual air from cartridge during prime
I can add a #6 cause based on past experience and that was a faulty cartridge and another was the system one had to be replaced.  This will happen if you get the red 10 at the very beginning of treatment and nothing can resolve the red alarm and ithis scenario keeps  Repeating every day   


Hope this helps.

[Simon Dog]

1.  keep a copy of the  major alarms (air/pressure). Along with probable cause and  actions to resolve  by your chair.

Or convince your clinic to issue a Nx2Me iPad.  When an alarm occurs, the number and short description pops up - and gives you an option to pull up a screen with the suggested  course of action.

Clinic advised us in training that a general rule...if you take of a UF volume of 2.0 or more use a rate of 1.0. If less than volume of 2.0 use .5 UF rate.

This is for people who are bad at math.   I add 300 (an approximation of 277) then divide the total amount by 3.25 to get the UF rate, since I target about 3:25 minutes on the machine.   Do it this way, and you won't be going to 1.0 unless you really really need to. 

[hatedialysis2]

1.  keep a copy of the  major alarms (air/pressure). Along with probable cause and  actions to resolve  by your chair.

Or convince your clinic to issue a Nx2Me iPad.  When an alarm occurs, the number and short description pops up - and gives you an option to pull up a screen with the suggested  course of action.

Hope your clinic is generous to offer you a Nx2Me iPad.   Mine is cheap!   I had to to throw a fit to get them to stop giving me NON STERILE alcohol pads (made in China) and to order button hole needles with steripicks!   

[Simon Dog]

Hope your clinic is generous to offer you a Nx2Me iPad.   Mine is cheap!   I had to to throw a fit to get them to stop giving me NON STERILE alcohol pads (made in China) and to order button hole needles with steripicks!

I am in an FMC 18 month trial program for the Nx2Me.    Retail is $99 per user, per month - not including the iPad.   The negotiated price is much lower, though I am not sure I should mention it so I won't.

The Nx2Me is a safety enhancing device, as it makes it VERY easy to continuously monitor your pressures; displays the actual blood flow rate (not the rate the machine is set at); AP and VP while clearing an excess pressure alarm; etc.   I was given a demo of the new version using bluetooth enabled BP machine and scale, and an anxious to get the upgrade.

My clinic gave me the choice between the JMS needles and the Medisense w/steripick.  After trying both, I prefer the JMS since I often have to "reach down" into the buttonhole to pull the scab out, and the steripick is better for surface level scabs.

"Non-sterile alcohol pads" is an oxymoron, since the alcohol lyses the pathogens.  Perhaps you meant non-sterile gauze?

I've never worried about the non-sterile gauze, since I always cover it with antinbiotic before application (mupriocin ointment), however, I know the clinic would order me the sterile packs if I preferred.     So far, I have not encountered any cheapness or cost issues on home supplies, except the prohibition of 200 or 250 filters on the BabyK (I am now on NxStage so this is irrelvant) without approval from the Fresenius P&T committee.

[hatedialysis2]

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm241750.htm

The link above is a notice sent in 2011 to health professionals, clinics , and hospitals about safety issues using non-sterile alcohol pads

[Simon Dog]

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm241750.htm

The link above is a notice sent in 2011 to health professionals, clinics , and hospitals about safety issues using non-sterile alcohol pads

Thanks - most informative.  I had though a non-sterile alcohol pad was in the same category as rust inside an oil can.

[Hootie]

Regarding use of Nx2me use, our nurse told us early on that Davita did not support that technology.  I will ask again..

On the math for take off rate that really makes sense. We will adopt that methodology. We do know it takes use about 2.5 hours to use the 25 liters of dialysate. From Dr Ager readings he says never to take off more that .7 rate for a 70 kg person.....math is .10 l rate times kg weight of person....1 times 70 is .7.

As far as clotting nurse talked to a field rep for NXStage today. She believes that you should never run machine only on a UF pull rate, i.e. Machine
needs  to have dialysate flowing at effective rate to end at about the same time. Otherwise, blood  is just circulating and will eventually clot as you are pulling.

We were running for over an hour just pulling UF at end yesterday. The NxStage person was going to verify and let's us know for sure on Tuesady. Will let you know the findings.
Machine pulling volume is also still not accurate. Above situation may affect that also.

[PrimeTimer]

I hate red alarms. Hate losing a blood circuit even more. Fortunately, it has not happened too often. I think twice (maybe 3 times) in the past 2+ years. I'd be suspicious if you found that the arterial needle had backed out a little. Maybe when it did the arterial access sucked air. We tape those suckers (needles) down good. Husband is fairly good about not moving his arm but we've gotten alarms before when he has. Really had to watch him when he had a cold and was coughing. Sneezing doesn't help either. He does that and my eyes get real big staring at his numbers on the machine. 

[hatedialysis2]

I use band aide to secure the needles.  Then tape.  The band aides do a better job securing and the are sterile. 

[Vt Big Rig]

We were trained to set the UF rate at 50% of the total UF to remove.

That usually leaves an hour plus where we are no longer pulling fluid. I have not had the clotting problems you describe.

We were also taught to use chevrons to secure the needles. I do not tape the down hard of I may get bad pressures.

[Simon Dog]

We were trained to set the UF rate at 50% of the total UF to remove.

That usually leaves an hour plus where we are no longer pulling fluid. I have not had the clotting problems you describe.

We were also taught to use chevrons to secure the needles. I do not tape the down hard of I may get bad pressures.

This 50% rule sounds like a hack to make things simpler in case a patient does not have a working floating point processor in their head.    I always run to pull fluid until the last 15 minutes.  The exception is I have been told to never run UF at less than .30.

If you are using blunts with buttonholes, the needles can be flipped safely and I find this reduces pressure by at least 20 points.    If you are using sharps, flipping is dangerous as you have a cookie cutter at the end of the needle.

[caregivertech1]

Agree with Simon Dog on removing 50% of volume in first hour. Poor training. Use the entire session. Ideally you should get a caution 5 minutes before your session is over. If you're exceeding the formula Hootie mentioned to remove all your fluid you're not dialyzing long enough.

[Vt Big Rig]

Luckily (? ?) because I am LARGE I never do exceed 0.1 per kg.

As I said before .....finally an advantage to being fat!!

[Hootie]

We have had no clotting issues since managing the Dialysate volume and UF volume finishing at about same time. We manage changes to dialysate rate to finish at same time. It makes the FF go down a little from 50 but that just gets a little more cleaning done. Nephrologist feels FF50 okay since it allows us to get done a little faster. She says its a trade off of cleaning  versus the patient and caregiver getting burned out by longer treatments 5-6 days a week over the longer  pull. Davita said early on their protocol was a maximum of FF50.

We are doing the max UF rate of .7 (71KG wife)  to help eliminate any BP issues. If the BP creeps down in the last 1/3 of treatment, we drop the UF rate to .4 or .3 and BP will come back up as the fluid shifts. We try to stay aways from boluses as you are just adding back in what you are trying to take off.

Just a couple thoughts...

[PrimeTimer]

IMHO, shorter treatments doesn't necessarily ward off burnout. Still have to do the same setup/tear down each time and make SAKs/hang bags. But even worse, shorter treatments might leave the patient/your loved one feeling mighty crappy because they didn't get enough cleaning.