AQUARIUS Continuous Renal Replacement Therapy …...AQUARIUS Continuous Renal Replacement Therapy...

AQUARIUS Continuous Renal Replacement Therapy Competency

CompeTenCy:

• Demonstrate the skills for the safe preparation and management of a patient and machine during continuous renal replacement therapy.

DefInITIonS:

• Statement of performance criteria.

• procedure or policy components.

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DATe: Competent not yet competent

1

oBJeCTIVe peRfoRmAnCe CRITeRIAeLemenTS ACHIeVeD

CommenTSyeS no

pRepARATIonprepare the patient.

prepare the environment.

Gather equipment required to Setup and prime the Aquarius Haemofiltration machine.

� explain the procedure to the patient and significant others

� ensure a safe environment for the patient and staff

• oH & S guidelines

• Infection control measures are met

� Identify access sites, and explain the benefits and the limitations of each.

• femoral, subclavian and internal jugular veins.

• Types of vascath’s available

� Collect equipment required for set up and priming the Aquarius machine

• Aquarius machine

• Aqualine circuit

• Aquamax filter

• Replacement fluid

• potassium Chloride (KCL)

• 1L normal Saline

• Anticoagulant – 50ml syringe

• 1 x 10ml Luer lock syringe

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2


CommenTSyeS no

pRepARATIon (ConTInUeD) � Gathers appropriate equipment accessing vascath according to unit protocol.

• Dressing pack x 1

• 2 x 10ml normal Saline

• Chlorhexidine solution / Betadine / 0.9% saline

• 2 x 5ml syringes

• 2 x 10ml syringes

• Sterile Gloves

� Can identify Dr’s written orders are correct and appropriate

• mode

• Blood flow

• post dilution

• predilution / Dialysate

• fluid loss

• Replacement solution (lactate / lactate free / citrate)

• Anticoagulation

• Signed and dated

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3


CommenTSyeS no

SeT UpSet up the Aquarius Aqualine circuit according to the manufacturer's recommendations and the ICU policy and procedure manual.

� Can identify and discuss the four renal replacement modes and the two Blood therapies.

• Can navigate to the Help prompt screen or Zoom Graphics to the 1st setof 7 set up steps.

• place pump segments into correct pump housing and wind in thedirection of the arrow.

• Correctly attach 4 pressure domes and close gates.

– pre-filter

– filtrate

– Access

– Return

• explain the significance of the Blood Leak Detection Chamber

• Heating coil correctly inserted and specifics explained.

• Connection of ADU. Describe the function of the ADU.

• Troubleshooting the ADU.

• Insert the Return Chamber and circuit into the clamp.

• navigate the screen to the second help screen or second set of 7 set upsteps.

• Connection of the filter. Which filter is chosen for therapy and why.

• point out the direction of the blood flow and why this is important.

• Connection of the filtrate port to the upper side port on the filter. Why is theport placed here? Would it make a difference to connect the filtrate port tothe lower side port on the filter?

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4


CommenTSyeS no

SeT Up (ConTInUeD) • Connection of the predilution / Dialysate port.

• What is the significance / benefit of predilution?

• When would dialysate be used and why?

• Why does dialysate run countercurrent to the blood flow?

• Connection of the drainage bag to the Access line. Why is this bagconnected to the Access line?

• Connection of the 1L priming bag to the return line. Why is this bagconnected to the Return line?

• Anticoagulant in the priming fluid? Discuss.

• Connection of the Replacement line to the replacement bag or chooksfoot. Swings scale to appropriate position.

• Connection of the filtrate line to the filtrate drainage bag or chooks foot.Swings scale to appropriate position.

How many bags can be hung on each scale?

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5


CommenTSyeS no

pRImInGprime the Aquarius circuit successfully according to company recommendations and unit policy.

CLAmp AnD pReSSURe TeSTperform Clamp and pressure test accurately and successfully.

� Commence priming.

• priming commenced at 80ml/min. Why?

• How long does priming of the Aquarius circuit take.

• priming at 150ml/min. Why?

• What do you do if part of the circuit fails to prime?

� navigates to the Clamp and pressure test post priming.

• moves Access line to the same saline bag as return line.

• What is the clamp and pressure test trying to achieve.

• Successful completion of clamp and pressure test.

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6


CommenTSyeS no

ReCIRCULATIonput the Aquarius machine into Recirculation mode

pRoGRAmmInGprogramme Aquarius as per medical orders and commence therapy.

� navigate to Recirculation mode.

• Commence recirculation successfully

• What is the purpose of recirculation?

• How long should you / could you re-circulate for.

• At what other times could you use recirculation?

• explain how you would change bed spaces with the Aquarius.

� Are the medical orders complete and correct and reasonable?

� navigate to the programming screen.

� programme Aquarius according to medical orders for the

• Blood flow rate

• Time Goal?

• fluid loss and goal loss

• predilution / dialysate rate and post dilution rate

• Anticoagulant rate

• Temperature goal.

• Reset option – discuss.

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7


CommenTSyeS no

ConneCTIonConnect patient to the Aquarius using hospital procedure and protocol.

� Connect patient to the Aquarius Haemofiltration machine

• Have you chosen a double or a single connection and why?

• What are the pros and cons of both?

• Have all equipment to connect to patient

• Does the vascath flush well?

• If not, potentially why not and what could be done to overcome this?

• Commence filling circuit with blood. Remain with the patient after pressingthe blood pump key to start.

• What is the default speed for the blood pump during connection?

• In single connection, when does the clamp come on?

• Commence therapy

� monitor the patients haemodynamic response to commencement of therapy

• observe access site and all connections

• Chart initial pressures

� explain the anticoagulation protocol

• explain why anticoagulation is used

• Identify when blood samples are taken to check anticoagulation levels

• State what target ApTT range is

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8


CommenTSyeS no

opeRATIonIdentify and explain the potential complications of CRRT.

opTImISATIon of THeRApy

� explain potential indications and complications related to

• Infection

• fluid imbalances

• electrolyte imbalances

• Bleeding

• Heparinisation

• Circuit clotting

• filter clogging

• fractured filter fibres

• Accidental disconnection / removal / dislodging of vascath

• Spontaneous hypotension

• Bradycardia

• Cardiac Arrest

� navigate to the more screen

• Discuss the prefilter pressure and its relevance to your circuit.

• Discuss the Uf variation and its relation to the balance system

• What is the meaning of the filtration Ratio

• Discuss the filtrate pressure

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9


CommenTSyeS no

ALARmSDemonstrate knowledge of the alarms and the ability to troubleshoot the Aquarius accordingly.

� explain alarm system signals - the status lights, the audible alarm and screen messages

• Demonstrate the use of the help screen

• Demonstrate and discuss error Help

� Discuss possible causes of the following alarms. Discuss potential action taken to rectify alarm.

• Balance Alarm

• Access alarms pressure too high or too low

• Return pressures too high or too low

• High pre-filter pressure

• High Tmp

• High pressure drop

• Temperature too high

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10


CommenTSyeS no

peRfoRmAnCe AnD opTIonSDemonstrate competent and confident user knowledge of the machine and flexibility.

CIRCUIT TAKe DoWn AnD SHUT DoWnUser to demonstrate cessation of therapy, safe and competent removal of the circuit and machine shut down.

� navigate to the History Screen. Identify where fluid loss can be found. Identify pressure records. Identify alarm history and discuss.

• navigate to where you would need to go if you wanted to change theanticoagulant syringe and complete the change.

• Demonstrate the recirculation procedure. When would this be used andwhy? Reconnect to treatment mode.

• perform and change of therapy eg : CVVHDf to CVVH and why you maywant to do this.

� Identify reasons for electively taking down the circuit. navigate to where circuit take down and machine shut down can be located.

• Can demonstrate safe and effective pressure removal from the circuit.

• Can identify appropriate circumstances when you may or may not returnthe patient’s blood.

• Demonstrate removal of circuit according to the user manual. See criteriabelow.

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11


CommenTSyeS no

SHUT DoWn (ConTInUeD)

CIRCUIT RemoVAL

� Demonstrates end Treatment

• Correct equipment collected for disconnection – 1L bag 0.9% saline – 1 x single spike – 1 x dressing pack – 2 x 10ml 0.9% saline amps – 2 x 10ml syringes – 2 x 2ml syringes – Heparin to hep-lock vascath

• Clamp and disconnect the access line

• Connect the access line to a bag of normal Saline using a spike

• follow the prompts on the screen

• Unclamp the access line and press the blood pump to start reinfusion ofblood back to patient.

• Disconnect return line and reconnect to return chamber air port. Unclamp.

� Identify pressures for safe removal of the Aqualine circuit. What do these pressures mean and how could these pressures influence your decisions?

• ensure all the clamps on the access and return lines are off.

• flush vascath lumens with normal Saline and Heparin lock bothlumens with Heparin according to unit protocol.

• open the pump doors

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12


CommenTSyeS no

CIRCUIT RemoVAL(ConTInUeD)

• Remove the filtration tubing from the filtrate pump in the direction of thearrow then remove the filtrate pressure dome from the filtrate sensor.

• If return pressure <400mmHg remove the pressure dome from pressuresensor.

• Is the return pressure >400mmHg? Decrease the pressure by connectinga syringe to the top of the return chamber and fill the syringe with fluiduntil the pressure on the screen is below 400mmHg. Remove the returnpressure dome from the return pressure sensor.

• Carefully remove the blood pump tubing by rotating in the oppositedirection (anti clock wise)

• Is the access pressure >400mmHg? Decrease the pressure byconnecting a syringe to the access infusion port before the access sensorand fill with fluid until the value is below 400mmHg. Remove the accesspressure dome from the access sensor.

• Is the Tmp >200mmHg? Decrease pre-filter pressure by connecting asyringe to the pre dilution port and fill the syringe with fluid until the Tmp isbelow 200mmHg.

• proceed with complete removal of the Aqualine circuit and all the bagsfrom the machine

• Select Aquarius off on the screen to turn off the machine. All equipmentmust be removed from the Aquarius and scales before the machine isswitched off. failure to remove circuit and bags from the machine prior tomachine shut down will constitute a failure of this section of competency.

• Dispose of equipment according to unit policy and oH&S guidelines.

• ensure patient is comfortable

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Assessment Decision: Competent not yet competent

Action/further Training Required/Date Set for next Attempt at Competency:

Comments:

Assessor’s Signature: Date:

Registered nurse’s Signature: Date:

References: Aquarius operators manual

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AQUARIUS Continuous Renal Replacement Therapy …...AQUARIUS Continuous Renal Replacement Therapy...

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