HF 440 Clinical Procedures Ver 1.1 Aug 2008

KEY POINTS

After a bag(s) change make sure there are no fluids line clamps ON, and the bags are punctured or screw connections are done with any connection plugs broken – open. The weight setting (alarm level weight) for substitution fluid empty must be correct for the number of bags hanging. If the alarm is set to 500 gms and 3 bags are hanging, the alarm may not sound until the bags are empty and the fluid supply runs out. This is because 3 empty bags and the fluid line will weigh more that 500 gms.

CROSS REFERENCE PROCEDURE

Fluids settings Waste empty Scales and fluids Priming – machine preparation

RELEASE DATE VERSION NUMBER

August 2008 1.1

HF440

CLINICAL PROCEDURE

TOPIC

Hourly fluid balance reading.

CLINICAL NOTE

No. 2

As with urine output measures, fluid loss during CRRT is often charted at the end of each hour in the ICU. This is usually in association with other vital signs charting. With Infomed HF 440, this can be done at any time by selecting a time period from the data window display down to a 15 minute interval. The fluid loss reading can be done over a longer time period, (e.g. 2 hrs) or a total value from the beginning of a treatment to audit values charted. In the data window, the reading is displayed as ‘weight variation’ (1gm=1ml). For replacement and dialysate volumes; these are displayed for reading also. Depending on local clinical protocols, the replacement and dialysate volumes delivered are often not recorded. Only the net loss for the hour is used representing the effective patient loss, in relation to the replacement / dialysate volumes being of more clinical importance.

PROCEDURE

To match the readings with the ‘working hour’, wait until the hour has past (~ 3mins). Press Data button on front screen. Change / edit the weight variation clock (- & +) for the hour required (usually the last hour); data displays in 15 min. intervals as the clock is advanced. Read value as weight variation (gm) = mls.

KEY POINTS

Fluid loss readings may not be the same each hour, and may not equal the set value. The achieved fluid loss will be influenced by ;
when weight (fluid) loss settings were adjusted during a given hour.

CROSS REFERENCE PROCEDURE

RELEASE DATE VERSION NUMBER

any alarm events during an hour, fluids bag changes or waste removal effectively reducing treatment time..

Substitution – Dialysate Fluids Bag change.

August 2008 1.1

HF440

CLINICAL PROCEDURE

TOPIC

HF 440 fluids and fluid loss setting.

CLINICAL NOTE

No. 3

In CVVH mode set UF flow in mL/hr. Set fluid loss (mL/hr.) from the window next to the ‘weight loss’ icon from the front operating screen.

Weight loss

100

Selecting ‘weight loss’ will change this box to ‘weight gain ’ and it will change to red. Weight gain will administer the amount programmable in the adjacent window and is not often used. UF flow is the total filtrate from the membrane providing convective solute clearance and becomes waste. The substitution rate is the UF flow rate amount unless a loss is prescribed as ‘weight loss’ (1gm=1ml). Any loss set in the rate window is deducted from the UF rate as substitution. This rate is not on display. e.g. UF flow = 2000 mL/hr. Weight loss = 100 mL/hr. Substitution rate = 1900 mL/hr. (not displayed)

Manual predil.

Automatic

50 %

The substitution fluid can be ‘manually’ split into pre (max. 70%) and post dilution administration site. ‘Automatic’ setting is an alternative to manual predilution. The HF440 will then automatically manage the predilution rate to optimise membrane filtration fraction. When no weight loss is set, the UF flow (mL/hr.) = the substitution rate (mL/hr.). In CVVHDF mode set UF flow and dialysate flow. Set negative fluid balance next to ‘weight loss’ icon mL/hr. Dialysate flow represents the fluid administered into the outer membrane casing for diffusive clearance of solutes. UF flow represents the rate of fluid removed from convective clearance of solutes. These 2 settings represent the total waste fluid removal (mL/hr.)

This UF flow rate is matched by substitution fluid with post dilution administration unless a fluid loss is required. When fluid loss is prescribed, substitution fluid is decreased by this amount. e.g. UF flow = 2000 mL/hr. Dialysate = 1000 mL/hr. Weight loss = 100 mL/hr. Substitution will equal 1900 mL/hr. Total waste rate is 3000 mL/hr.

PROCEDURE

Touch the screen buttons to active the settings for : UF flow (mL/hr.) Dialysate (mL/hr.) Weight loss (fluid loss required, 1 gm = 1 mL.) Manual predilution (%) or Automatic Use validate
for each setting, and again to confirm and return to front operating screen view. Use  to cancel a setting change.  Substitution rate is not displayed, this value is equal to the UF flow unless a fluid loss is set. The substitution rate is then the UF flow rate – loss rate.

KEY POINTS

CROSS REFERENCE PROCEDURE RELEASE DATE VERSION NUMBER



In CVVHDF mode, the UF flow setting and the dialysate rate setting add to become the total diafiltrate (waste) amount mL/hr.



If ‘weight gain’ (red colour) HF440 is administering fluid – no negative fluid loss from the settings.

Hourly fluid balance reading.

August 2008 1.1

HF440

CLINICAL PROCEDURE

TOPIC

Starting treatment ; patient connection

CLINICAL NOTE

Additional rinsing

No. 4

After completion of priming the HF440 there are several options for further use. Additional rinsing. This option if pressed to continue priming the circuit and can be useful for removing further air bubbles. Check that sufficient fluid remains in fluid - priming bag. Select ‘additional rinsing’. Machine will begin further priming immediately and a display of the volume used. Select the green validation tick when finished for stopping this and returning to the main screen for connection and treatment.

Shutdown

Shutdown. Used when the machine is not intended for use immediately or when you need to move the machine and need to power off during this time. Turn off machine at back of machine before turning off mains power and removing power cord. To re-power and continue use, return to treatment ready screen by reconnecting mains power and turn on at mains switch before power On using button on back of machine.

PROCEDURE Treatment

Start

Start treatment. Press the ‘treatment’ button at the end of priming. The screen changes to the operating screen; blood pump and fluids settings will be displayed. The fluids settings will be at ‘zero’, and the blood pump at 50 mL/min. The ‘start’ button will be flashing. Connect both blood lines to the patient access catheter and ensure clamps are off. Follow local procedures for this. Select ‘start’, the blood pump only will begin rotation at 50mL/min. , this can be reduced if desired. Gradually increase blood pump speed as tolerated; using the blood pump button. Wait until the circuit is full of blood. When the blood pump is at treatment speed. e.g. 200

mL/min., set the treatment fluids in this exact order and validate each one using
. 1. Set UF flow 2. Set Dialysate flow for CVVHDF mode only. 3. Set weight – fluid loss. After a short time the fluids pumps will start automatically. Check and or reset the fluid temperature from the front screen ‘temperate’ button. Press the pressures button and review – set the alarms.

KEY POINTS

Patient connection can be associated with hypotension. Slow blood pump speed until the circuit is full of blood can reduce this. The fluids pumps on the HF 440 will not begin until the scales have measured the fluids weights after starting ~ 1 min.. Recheck for any clamps on the fluids and the waste bags/bottle before starting a treatment.

CROSS REFERENCE PROCEDURE RELEASE DATE VERSION NUMBER

HF 440 fluids and fluid loss setting. Priming procedure. August 2008 1.1

HF440

CLINICAL PROCEDURE

TOPIC

Waste Fluids Bag / Bottle change.

CLINICAL NOTE

No. 5

Waste fluids bags will require changing when they are full. The frequency of this is related to the UF flow, loss and or dialysate settings (mL/hr). The machine scales weigh the bags and as weight increases to the preset alarm level (kg) the alarm will sound. This level will require a different setting depending on a decision to hang 2 or 3 bags. The weight alarm level is set with consideration of the total weight of the bags, waste bottle and fluid included. e.g. 2 bags or 10 L, set alarm level at 10 KG. For 3 bags or 15 L set the alarm at 15 KG. For a bottle collection with a 20 L bottle, 15 KG is common. The alarm level can be changed when the alarm sounds and the alarm window displays using the ‘set levels’ touch button. This can also be set after priming, before treatment from the ‘change container’ touch button. To edit this during treatment, simply lift the bags off the scales to set-off the alarm. Silence the alarm, select the ‘adjust alarms’ touch button, change the ‘waste full’ weight and validate, then validate again to continue treatment.

PROCEDURE

The HF 440 will alarm with a pop up window. Press the alarm silence (red bell) button. Change the full bag(s) hanging with new empty bags onto scales hooks. Make sure each bag is opened, no line clamps on. Stabilise the bags from movement. For bottle emptying ; Connect power supply to pump on back of machine. Turn on power, wait until bottle empties and pump sucks air. Turn off pump power. Now press the green tick
on the front screen.

KEY POINTS

CROSS REFERENCE PROCEDURE

The weight setting (alarm level weight) for waste fluid empty must be correct for the number of bags hanging. If the alarm is set to 15KG and 2 bags are hanging, the alarm will not sound until the bags are overfilled or a waste pathway alarm.

Fluids settings Scales and fluids Priming – machine preparation

RELEASE DATE VERSION NUMBER

August 2008 1.1

HF440

CLINICAL PROCEDURE

TOPIC

Termination of treatment ; patient disconnection

CLINICAL NOTE

No. 6

It is always desirable to terminate treatment electively before sudden circuit clotting and blood flow obstruction. When this occurs, patient blood is usually wasted. Flushing the circuit blood back to the patient is preferred and should be a clinical aim. Different protocols reflect the decision for when a circuit should be electively terminated. High TMP can reflect filter clotting and or high Venous pressures air chamber clotting. Refer to local protocols for definition of circuit clotting. The HF440 front operating screen includes an option for “terminate treatment”. Selecting this option activates a window requiring further validation to confirm this choice. Cancellation is possible by selecting
. However, if ‘blood pump stop’ is pressed within the window after validation, the ‘back’ function is not possible. Manual termination can also be done without using the ‘terminate treatment’ option. This is commonly done in clinical use and may be preferred by some users.

PROCEDURE Terminate treatment

Press ‘terminate treatment’, follow the on screen instructions after validating this choice. The next screen indicates the treatment volumes, final data for fluid loss and the ability to stop the blood pump. Treatment is then stopped. It is common to provide the saline flush from a 500 mL bag connected into the circuit on the ‘arterial’ line before the roller pump as the saline flush. After opening this line, clamp the patient access catheter – ‘arterial’ limb to stop blood outflow and allow saline entry. Manual termination. Prepare saline bag 500mL for flush back connected to arterial line at ‘T piece’ before main blood pump.

Check data screen for final fluid loss measurement – advance clock to view, the current hour. Press ‘back’ to main screen. Select ‘stop’ option from operating screen menu. This will halt all fluids administration and waste removal. The blood pump will also reduce to 100 mL/min. Stop

Open the saline flush line, clamp the arterial access limb and wait until the blood is flushed back. Press desired blood flow and change to ‘0’ – ( zero) and validate. Treatment is also terminated, the machine is now safe to turn off and remove the circuit,.

KEY POINTS

Stop

CROSS REFERENCE PROCEDURE RELEASE DATE VERSION NUMBER

Terminate treatment selection is not absolute, cancellation is possible if the blood pump stop option is not selected. Selecting ‘stop’ on the front operating screen stops the fluids and waste removal, slows the blood pump to 100 mL/min.

HF 440 fluids and fluid loss setting. Starting treatment ; Patient connection August 2008 1.1