Is Your Patient Receiving the Treatment You Prescribed?

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1 Rx Tx Medical Directors Pre-Symposium Dallas, Texas September 22, 2011

2 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

3 Prescription Staff Disposables Equipment Treatment

4 Prescription Dialysate 2.0K / 2.5Ca / 1.0Mg / 100Dex Granuflo / NaturaLyte Base Sodium 137 meq/l Sodium Variation 155 meq/l meq/l Bicarbonate 38 meq/l (Total Buffer?)

5 Staff Machine Calibration Granuflo Preparation Specific Gravity Test Bicarbonate Preparation Final fill volume Formula Selection Machine entry Base Sodium & Bicarbonate Machine entry Dialysate Verification Actual Conductivity and ph Theoretical Conductivity Variance

6 Prescription Treatment Dialysate 2.0K / 2.5Ca / 1.0Mg / 100Dex Granuflo / NaturaLyte Base Sodium 137 meq/l Sodium Variation 155 meq/l meq/l Bicarbonate 38 meq/l (Total Buffer?)

7 Rx Tx Alarms Curtis Woods

8 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

9 Question Fresenius 2008 hemodialysis machines monitor dialysate ph: a) Yes, directly b) Yes, through conductivity c) No

10 Answer Fresenius 2008 hemodialysis machines monitor dialysate ph: a) Yes, directly b) Yes, through conductivity c) No (Staff must perform ph and Conductivity tests to ensure acid and bicarbonate concentrates are correctly proportioned)

11 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

12 Machine Alarms QUIET PLEASE Today s Culture Tight Schedules, Busy Staff Are alarms reset to quiet the machine? Pressures can migrate with each reset Marching toward limit extremes

13 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

14 Question When using a highflux dialyzer such as the Optiflux 180, TMP alarms when UF removal changes by: a) 0.5 kg/hr b) 1.0 kg/hr c) 1.5 kg/hr d) 2.0 kg/hr

15 Machine Alarms TMP Transmembrane Pressure (TMP) In a typical low flux treatment, it would take a leak equivalent to 0.3L / hr to cause a TMP alarm In a typical high flux treatment, it would take a leak equivalent to 2.2L / hr to cause a TMP alarm

16 Machine Alarms What can the MD do? Online Pressure Holding Test Assure this feature is turned ON!!!! Runs every 12 minutes during a treatment Catches hydraulic leaks of 300 ml/hr

17 Answer When using a highflux dialyzer such as the Optiflux 180, TMP alarms when UF removal changes by: a) 0.5 kg/hr b) 1.0 kg/hr c) 1.5 kg/hr d) 2.0 kg/hr (Kuf = 55 ml/mmhg/hr) Pressure Holding Test must be Activated

18 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

19 Question Shifting conductivity limits from the default position can produce variations in NaCl from prescription of: a) 2 meq/l b) 4 meq/l c) 8 meq/l d) 10 meq/l Machine settings: 137 meq/l Na / 35 meq/l Bicarbonate TCD = ms

20 Conductivity Machine Alarms Conductivity Limits are +/- 0.5mS/cm around theoretical/target conductivity (TCD) TCD is the target conductivity for the prescribed concentrate, Base Na+ and Bicarbonate value

21 Dialysate Screen - TCD Dialysate Screen - TCD

22 Conductivity Limits Conductivity Limits Limits can be adjusted either up or down an additional 0.5mS/cm Maximum alarm setting is + 1.0mS/cm of TCD with the lower limit at TCD

23 Conductivity Limits Conductivity Limits Minimum alarm setting is 1.0mS/cm of TCD with the upper limit at TCD 0.9mS/cm variation from TCD

24 Answer Shifting conductivity limits from the default position can produce variations in NaCl from prescription of: a) 2 meq/l b) 4 meq/l c) 8 meq/l d) 10 meq/l Machine settings: 137 meq/l Na / 35 meq/l Bicarbonate TCD = ms

25 Rx Tx NaCl and Buffer Brooks Rogers

26 Two Buckets a Pulley & Rope Two Buckets a Pulley & Rope Three Stream Proportioning Systems How They Really Work

27 9000 Series

28 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

29 Question Changing from NaturaLyte acid concentrate to Granuflo without changing the bicarbonate prescription can alter total delivered buffer up to: a) 2 meq/l b) 3 meq/l c) 4 meq/l d) 5 meq/l

30 Acid Concentrate Buffers Acid Concentrate Buffers Liquid Acetic Acid - (H+ Acetate-) Powder Diacetate - (H+ Acetate- & Na+ Acetate-)

31 Total Delivered Buffer Total Delivered Buffer HCO 3 + HAcetate = H 2 O + CO 2 + Acetate Liquid and Traditional Dry Acids Bicarb Acid 43meq HCO 3 4Meq HAcetate 37-4=33 33 Bicarb + 4 Acetate = 37 Total Buffer Granuflo Bicarb Acid 43meq HCO 3 4Meq HAcetate 4Meq NaAcetate 37-4=33 33 Bicarb + 4 Acetate + 4 Acetate = 41 Total Buffer Granuflo delivers 4 meq/l additional Acetate in the form of NaAcetate

32 Default Setting Default Setting Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.22 Can be changed by the operator/machine

33 Raise Bicarb to 39 meq/l Raise Bicarb to 39 meq/l Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.32 Can be changed by the operator/machine

34 (G) Default Setting GranuFlo (G) Default Setting GranuFlo Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.22 Can be changed by the operator/machine

35 (G) Raise Bicarb to 39 meq/l (G) Raise Bicarb to 39 meq/l Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.32 Can be changed by the operator/machine

36 Answer Changing from NaturaLyte acid concentrate to Granuflo without changing the bicarbonate prescription can alter total delivered buffer up to: a) 2 meq/l b) 3 meq/l c) 4 meq/l d) 5 meq/l

37 Buffer Prescription Facts Buffer Prescription Facts Single value prescriptions for all patients within a clinic result in a normal distribution curve for patient serum buffer Changes in this single value prescription only moves the curve, shifting problems for the outliers between acidosis and alkalosis Individual prescriptions may be necessary for some patients and Total Buffer must be considered when switching between different types of acid concentrate

38 Objectives Show the significance of staff s independent check of conductivity and ph Show significance of pressure alarm limits Show significance of Online Pressure Holding Test Show the impact of shifting conductivity alarms from default settings Show the impact of changing the type of acid concentrate on dialysate buffer Show the impact of using sodium variation

39 Question Improper use of Sodium Variation can result in patient sodium loading of: a) 2.8 gm NaCl for every 5 meq/l over pt. base b) 4.5 gm NaCl for every 5 meq/l over pt. base c) 8.7 gm NaCl for every 5 meq/l over pt. base

40 Default Setting Default Setting Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.22 Can be changed by the operator/machine

41 Raise Sodium to 150 meq/l Raise Sodium to 150 meq/l Acid Bicarb Dialysate SODIUM POTASSIUM CALCIUM MAGNESIUM CHLORIDE SODIUM ACETATE ACETIC ACID (ACETATE) BICARB TOTAL BUFFER DEXTROSE, gm/l THEORETICAL CONDUCTIVITY THEORETICAL ph 7.17 Can be changed by the operator/machine

42 Answer Improper use of Sodium Variation can result in patient sodium loading of: a) 2.8 gm NaCl for every 5 meq/l over pt. base b) 4.5 gm NaCl for every 5 meq/l over pt. base c) 8.7 gm NaCl for every 5 meq/l over pt. base (recommended dietary intake is 2.0 gm/day)

43 Key Points for Review Key Points for Review Staff must check Conductivity and ph with an independent meter every treatment Shifting Conductivity limits from the default position can result in up to a 10 meq/l variation in delivered sodium Pressure Holding Test Activated for TMP Total delivered buffer is the sum of the prescribed bicarbonate and up to 8 meq/l of base buffer contribution from acid concentrates A positive sodium gradient, such as that induced by inappropriate use of sodium profiling, can lead to a patient sodium load that is far greater than dietary restrictions

44 Questions Thank You!!!

Fresenius Medical Care North America Corporate Headquarters Medical Department To: FMCNA Medical Directors 95 Hayden Ave

Fresenius Medical Care North America Corporate Headquarters Medical Department To: FMCNA Medical Directors 95 Hayden Ave Lexington, MA 02420-9192 From: J. Michael Lazarus, M.D. Date: July 5, 2005 Re: Bicarbonate