Prismaflex SystemBasic Set-up

Facilitates electronic charting

Calculates therapy delivered

®

Each softkey changes drawings appropriately

Blood Leak detector

(BLD)

Automatic loading with Bar Code Reader identifies filter set

Ensure correct connection of solutions

Recommended priming volume

and syringe

Setup - CVVHDF

Setup - CVVHD

Setup - CVVH

Setup - SCUF

Priming only continues while key is pressed.

Make sure priming solution is adequate.

<Insert REPRIME screen>

• Requires one full bag of priming solution. • Automatically primes all lines.• Check effluent bag if change is required.

Press CONTINUE only if ready to start treatment.

Prismaflex System

Starting Treatment

Calculating Patient Fluid Removal

Net fluid removal hourly (physician order)

+ Non-Prismaflex intake (IV, TPN, etc.)

- Non-Prismaflex output (urine, etc.)

= Patient Fluid Removal Rate (set in Prismaflex)

Pre-Blood Pump (P.B.P.)

• Pumps solution into blood compartment at access

• Purpose:• Direct pre-blood pump infusion of other solutions• Optional pre-dilution replacement solution• For anticoagulation

• Fluid volume automatically removed by effluent pump• Do not include in calculation as patient intake

• PBP linked to blood pump• Blood pump compensates for PBP infusion rate• PBP rate must not exceed blood flow rate

Press ENTER after all flows are set.

Press Continue if settings are correct.

Press softkey and follow step-by-step instructions.

Prismaflex System

Treatment Management

Therapy Mode

Pressures & Limits

Pressure Graphs

Main operating screen during treatment

Provides Filter and Vascular Access assessment parameters

Provides information on condition of filter.

Note: Advisory alarm occurs when blood pump/flow is stopped for >60 sec.

200 ml

1000 ml

Pre

500 ml

1000 ml

200 ml

1000 ml

0.0 ml

Immediate

0.5 ml

Monitor cumulative fluid balance hourly for accurate

fluid management.

Press to view a different time period

• Recommended Delivery of at least 200cc/hr post-filter replacement

Deaeration Chamber

• Monitor chamber level hourly with routine I&O

• Important NOTE: • Keep Blood at designated level on

deaeration chamber at all times. • If fluid level is too high and return line clamps

off, fluid may enter machine through monitor line

• If fluid level is too low, an “Air in Blood” alarm may occur

Prismaflex System

Basic Alarm Overview

Safety Feature Components

Air Bubble Detector

Blood Leak Detector

Return Line ClampBlood/Patient Sensor

Alarm Lights

Display screen

Pressure Monitors

Scales

Bar Code Reader

Syringe Pump

Pressure Monitors

Prismaflex Types of Alarms

Highest priority

Lowest priority

Highest priority

Lowest priority

1234

1. Warning - Patient hazard• Patient and System at risk • Needs immediate action• Treatment suspended

2. Malfunction - Failure of safety system• Patient and System at risk • Needs immediate action• Treatment suspended

3. Caution - Informs operator of an action• Patient and System not at immediate risk• Needs action• Treatment continues; Blood and syringe flows continue

4. Advisory - Informs operator of an action• Patient and System not at immediate risk• Treatment continues; Blood and syringe flows continue

•Read Screen

•Follow Steps

•Check Manual

•Read Screen

•Follow Steps

•Check Manual

The THREE Troubleshooting Commandments

Alarm Screens

Alarm Screens Softkeys

Silences alarm, beeps every 2 minutes

Repeats test for alarm condition

Overrides alarm for 60 seconds

Clears alarm and restarts pumps

Allows user to change set

Opens return line clamp

Allows user to view list of active alarms

MUTE

OVERRIDE

RETEST

CONTINUE

NEW SET

OPEN CLAMP

EXAMINE ALARMS

UNLOAD FLOW RATES

DIS- CONNECT

CHANGE SYRINGE

MUTE

Pressure Monitoring

-50 to –150+100 to +250

> +50 to -150

+50 to +150

Access Pressure

•Pressure created by pulling blood from patient through access

•Access pressure usually negative • Blood flow rate• Blood source

(e.g., CVC, AV Fistula, blood access device)

•Typical pressure:

-50mmHg to -150mmHg

Access-50 to –150

Confirm positive range only

if connected to external blood device or AV Fistula

Confirm positive range only

if connected to external blood device or AV Fistula

Positive range requires re-confirmation from user. Positive range requires re-confirmation from user.

Return Pressure

•Pressure created by returning blood to patient through access

•Uses internal pressure sensor/ deaeration chamber monitor line

•Usually positive

•Typical pressure:

+50mmHg to +150mmHg

Return+50 to +150

Return Line - Monitor Fluid Barrier (Code 20)

•Setup: Secure connection of fluid barrier to return pressure port

•Monitor Deaeration Blood level in deaeration chamber hourly during treatment

•Adjust chamber if necessary (SYSTEM TOOLS)

Wet fluid barrier may cause errors in return pressure readings.

Wet fluid barrier may cause errors in return pressure readings.

Maintain level

Filter Pressure

•Circuit pressure to push blood into filter

•Most positive pressure displayed

•Typical pressure:

+100mmHg to +250mmHg

Filter+100 to +250

Effluent Pressure

•Pressure depends on:• Therapy and UFR

•Typical pressure:

+50mmHg to -150mmHg

Effluent> +50 to -150

Software Calculated Pressures

Prismaflex

calculates pressures

so you don’t have too!!

• Trans-membrane Pressure (TMP)

• Filter Pressure Drop (∆P Filter)

• Trans-membrane Pressure (TMP)

• Filter Pressure Drop (∆P Filter)

Trans-Membrane Pressure (TMP)

•Pressure exerted on filter membrane during operation

•Reflects pressure difference between fluid and blood compartments of filter

•Calculated by Prismaflex software

Trans-Membrane Pressure (TMP)

Calculated and automatically recorded:• Entering Run mode - blood flow is stabilized• Blood flow rate is changed• Patient fluid removal rate is changed• Replacement solution rate is changed

Membrane permeability TMP Membrane permeability TMP

Filter Pressure Drop (ΔP Filter)

• Change of pressure from blood entering filter and leaving filter

• Determines pressure conditions inside hollow fibers

• Calculated and automatically recorded:• Entering Run mode• Blood flow rate is changed

• Calculated by Prismaflex software

Access and Return Pressures

Is it the Vascular Access??

Access Pressure Extremely Negative

Due to vascular access/catheter:• Sitting against vessel wall• Fibrin coating on outside of catheter lumens• Clots on inside of catheter lumens• Size is too small (Adults require 11 Fr or larger)

Other possible causes:• Stopcocks inline with Prismaflex set• Position of patient

Kinking bloodlines• Ensure lines are unclamped

Return Pressure Extremely Positive

• Due to vascular access catheter:• Sitting against vessel wall• Fibrin coating on outside of catheter lumens• Clots on inside of catheter lumens• Size is too small

Adults require 11 Fr and larger

• Other possible causes:• Stopcocks inline with Prismaflex set

Infusing something into Return side of the Prismaflex circuit can increase Return Pressure

• Position of patient• Kinking bloodlines• Ensure lines are unclamped

WarningAccess Disconnection-Pressure is zero

•Disconnection•Pressure pod not installed properly•Debris in pod housing•BFR too low for vascular access •Pressure sensor failed

•Press MUTE•Secure connection•Press OVERRIDE•Increase BFR•Clean, reinstall, reposition pod

• Self-test or manually

•Consult screen display for more info•Follow hospital protocol if unable to repair.

Possible Causes: Possible Solutions:

WarningReturn Disconnection-Pressure is zero

•Disconnection•Pressure pod not installed properly •Dirty pod•BFR too low•Pressure sensor failed

•Press STOP•Press MUTE•Increase BFR•Clean, reinstall, reposition pod•Press OVERRIDE•Follow hospital protocol if unable to repair.

Causes: Solutions:

Advisory: “Cannot Detect . . .”

• Advisory: Cannot detect access: 0 to –10mmHg• Use of large bore patient catheter• Low blood flow for type of vascular access• Self-clears if condition does not exist

• Advisory: Cannot detect return: 0 to +10mmHg• Loose or disconnected return line• Low blood flow for type of vascular access• Loose or disconnected chamber monitor line• Wet fluid Barrier filter

Hemofilter Pressures

Is it the Filter??

Filter Extremely Positive

•Line clamped, kinked•High return pressure•Clotting in filter has begun•Pressure sensor failed

•Press MUTE•Remove clamps or kinks•Lower BFR•Press CONTINUE•Change set

Possible Causes: Possible Solutions:

Safety Features

Blood Leak Detected (BLD)

• Leakage of blood to the fluid side of the hemofilter

•Other causes:• Air in effluent line• Effluent line not properly installed in BLD• Myoglobin (trauma, burn, Rhabdomyolysis)• Bilirubin (Liver failure, Hyperbilirubin) Conjugated only• Debris in sensor housing

Blood Leak Detected: First Actions

• Confirm that line is properly installed• Press OVERRIDE• Press line into detector from the bottom up• Press OVERRIDE

• Clean inside of detector with a lint-free cloth and isopropyl alcohol• Dry thoroughly• Reinsert line

BLD Alarm: Normalize BLD

• Press SYSTEM TOOLS on Status screen

• Press NORMALIZE BLD soft key • Follow instructions• Observe or test effluent for blood

• If positive for blood, press END TREATMENT • (Do not return blood,?) and set up new circuit .

Effluent Testing Do’s & Don’t’s

•When testing effluent, DO:• Use a quantitative method:

• Run effluent as though it were blood• Perform RBC count• Results should be zero• Run as Peritoneal cell count

•When testing effluent DO NOT:• Use Hem-a-Stix or other urine dipstix• Run effluent as urine sample

Air Bubble Detector•Ultrasonic

•Located along return line

•Alarm activated by:• air in blood• micro air

Air Detector

Return Line Clamp

Considerations for Air Detector

• Monitor blood level in deaeration chamber hourly with I&O

• Keep blood level at designated line on chamber• Blood level too high with return line clamping may allow Blood

to enter fluid barrier and interior of control panel • Fluid level too low may cause “Air in Blood” alarm

Air in Blood

Possible Causes:•Improper connection

• Catheter• Anticoagulation• Replacement line• Blood warmer connector

•Improper priming

•Return line not installed properly

•Access pressure extremely negative

Possible Solutions:•Check and tighten connections

•Install return line properly

•Perform air removal procedure:• Status Screen• SYSTEM TOOLS • ADJUST CHAMBER

•Lower blood flow rate

•Replace filter set

Warning: Wrong set loaded

• Occurs during SET-UP• Re-select loaded filter• Change filter set to prescribed therapy• Check set-up and reposition filter set properly• Re-load correct set• Check that return line is tightly inserted into

pressure port or blue thing not tight enough• Clean Bar Code reader window

Syringe Pump

• Malfunction: Syringe not loaded• Occurs during setup• Reload syringe in “CHANGE SYRINGE”• RETEST• Disable syringe function

• Advisory: Check syringe line - clamped line• Occurs during setup and treatment• All pumps stop (8 sec) to retest• If unresolved, followed by next alarm

• Warning: Syringe empty/clamped• Occurs during setup and treatment• Unclamp syringe line• Replace with filled syringe

Advisory: Time to Change Set

•Occurs after 72 hours or when 780 L of fluid is processed

•Available in HISTORY SCREEN, then CHANGE PERIOD

•Occurs after 72 hours or when 780 L of fluid is processed

•Available in HISTORY SCREEN, then CHANGE PERIOD

CRRT Scales

Warning (CAUTION): Scale open

Specific scale identified

Inspect scale component and remedy, then close properly

Warning (CAUTION): Effluent bag incorrect

Hanging effluent bag does not match set “Allowed effluent volume”

No bag on scale or bag is partially supported

Change the effluent bag or modify “Bag Volume”

Hang appropriate bag

Allow bag to hang freely

Warning (CAUTION): Bag container empty

Bag is specified Bag is empty or supported

Warning (CAUTION): Effluent bag full

Bag is specified Inspect scale for foreign object

Replace effluent bag

CRRT Scales

Advisory:

Clamped bag

Early notice of clamped bag or line immediately after a bag change

Inspect bag/line for patency

View history for flow volume

May cause unsafe fluid balance errors

®

Fluid Control Unit

Continuous Monitor feedback Balances fluid between:• Scales• Software • Pumps

“Incorrect Weight Change Detected” fluid variance in Patient Fluid Removal

compare to the set Fluid Removal rate

Determined by:• Patient Size• Patient condition•Hemodynamic stability

Fluid Safety Guard Setting Excess Patient Fluid Limit

CRRT Set Default Range

M60 130 ml 100-200ml over 3hr

M100

HF1000

HF1400

330 ml 100-400ml over 3hr

Expected Variance in Fluid Removal

• Alarm condition that stops fluid pumps • Treatment is stopped , then resumed• Change bag interruption

A small amount of variance from set patient fluid removal rate is normal due to interruptions in

treatment.

A small amount of variance from set patient fluid removal rate is normal due to interruptions in

treatment.

Incorrect Weight Change Detected

Causes:• Frangible pin(s) in solution bags not completely broken• Kinked or clamped fluid line• Bags swinging on scale hook• Leaking bags or bag lines not properly connected• Foreign object on scales• Partially supported bags (not hanging freely)

Occurs when weight on one or more scales does not change according to set fluid flow rates.

Occurs when weight on one or more scales does not change according to set fluid flow rates.

What triggers the Incorrect Weight Change Alarm?

• 40ml+/- for immediate variance from operator set patient fluid removal

• 120ml variance in one hour from operator set patient fluid removal

Incorrect Weight Change: Patient Fluid LOSS

If: Dialysate, replacement, or PBP

flow is obstructed

Then:Fluid may be pulled from patient

through blood side of filter

Incorrect Weight Change: Patient Fluid GAIN

If: Effluent flow is obstructed

Then: Fluid may be infused to the

patient from blood side of filter

Early Advisory Alarms

•Provides early notification of flow problems•Prevents more serious alarm situation/s•All fluid pumps are operational

Fluid Safety Guard CAUTION: Incorrect Weight Change Detected

Identifies affected scaleProvides current information on unexpected patient fluid loss or gained over a 3hr cumulative RUN time Operator-set fluid limitProvides on-line troubleshooting instructions

End Treatment

•What causes the End Treatment Alarm?

The excess pt fluid loss or gain limit has been met or exceeded.

Fluid Safety Guard Excess Pt.Fluid Loss or Gain Limit Reached

•Provides instructions to END TREATMENT•Treatment suspended; blood pump continues; fluid pumps stopped•Assess patient’s fluid status and need for medical intervention/s

References and Further Reading

•Prismaflex Operator Manual •Prismaflex Tutorial•Prismaflex Training Guide Software v3.20

QUESTIONS?

Prismaflex System

End Treatment

STOP Softkey

End Treatment: Three choices

•End treatment

•Change set

•Recirculation

Return Blood

START RETURN activates blood pump only when pressed.

When blood returned, press CONTINUE.

Recirculate•Temporarily disconnect

•Requires:

•Blood return

•Disconnect patient

•Circulate NS

•Re-prime set before connecting patient

•Blood pump is activated

•Only immediate syringe bolus, if syringe is activated during treatment

Note: Volume of NS recirculate adds to total blood/fluid processed for filter. Advisory alarm to change set occurs at 780L.

End treatment Procedure:

•Disconnect patient

•Unload and remove filter set

•Disconnect bags

It is possible to end treatment with or without returning patient’s blood.

End Treatment

Gambro is here to assist you 24 hours a day7 days a week:1-800-525-2623

References and Further Reading

•Prismaflex Operator Manual •Prismaflex Tutorial