Nocturnal problems

hi all, Lin is a friend of mine from a PKD support group and she recommended that I post the difficulties I’ve been having here, so here goes:
I am in a nocturnal dialysis program with Rogosin in NY. I have an experimental machine supposedly made for home, nocturnal use. well, yes, if you don’t mind being wakened at 4:30 a.m. with screaming alarms of low conductivity because, tho you went to bed with a jugful, it’s now gasping for breath. so you attempt to return your blood with the alarm screaming in your ear because you muted it but it only took for so long.
then, lo and behold, the TMP is alarming and the blood pump is shut down, so you have to pump it manually.
that has been a typical treatment for me. when I tell my trainer about the conductivity she tells me, “it shouldn’t do that”. well, duh! I agree it shouldn’t do that but it does.
it also doesn’t just shut down quietly after a treatment. it tells me my UF level is reached and then goes through one alarm after another. there may be a trick to it to get it to go away quietly.
I doubt that any of you are using this Fresenius 2008K because there are not many out there but if you have any suggestions I’d like to hear from you.

What do you mean gasping for breath? Is the bicarb out? How long are you running? How full is the bicarb jug when you start? Is the conductivity low or high? When the machine is out of conductivity it should go into by pass and still run. You should be able to push the reset button to clear the TMP alarm.
And the machine should reset the TMP so you don’t have to do a manual rinseback. Not saying you wouldn’t have to do this more than once to get rinsed back. I ask the above questions because depending on the answers; I pretty much think you should just plain blank tell your nurse trainer you need a serviceman for the machine.

Once your UF is reached it alarms. Then when you clamp the line to rinseback the arterial line the venous pressure will change and this will cause an alarm. You can either push mute until the rinseback of the arterial alarm is complete (which is what I do) or you can hit the override button to clear the venous pressure alarm. Once the arterial side is rinsed back and you do the venous side it shouldn’t alarm anymore. The Fresenius 2008K does have bugs. Our nocturnal program just started using them and the training nurse told me they are experiencing more trouble with them than with the old 2008H machines I use. But they do call the serviceman and get the problems corrected.

Helen, Are you getting the help and support you need from Rogosin? They use the K machines at the unit I’m at now, and used the H machines at previous units. I was told by the techs they’re basically the same machine, but that the K machine has more bells and whistles. Too, both machines have added capabilities if needed or wanted, by the addition of computer modules. I hope that they can figure out what the problems are; I sure would hate to see you have to go back to the unit and back to the city. Lin.

Marty you are right about all the "should"s. that’s what my trainer tells me “it should”. all the shoulds in the world won’t make it do it.
I start with a full jug of bicarb and when it quits it is near empty. down to maybe an inch or less. that’s 9.5 liters. I’ve never seen a “high conductivity” alarm and don’t even know what they look like.
as to the TMP alarm, reset doesn’t have much effect on it.
I trained on this machine at Rogosin, doing normal (3 hr) sessions and there was sufficient bicarb, thus conductivity. we still had the problem of alarming constantly during shut down which we solved by pulling the acid shunt.
I do believe the 2 nurses who run the nocturnal unit are so overwhelmed because they have to do EVERYTHING there.

oh Marty, to answer one of your questions, I aim for 8 hrs, or if I have something scheduled, 7 1/2 hrs. I’m not a person who can get by on 6 hrs of sleep.

Spiderwoman, Ok from what you are telling me, I don’t think it’s anything you can fix. I thought maybe you were running out of bicarb. If you got a low conductivity or hi conductivity this would tell which was the problem acid or bicarb. But it sounds like it must be acid if it happened during training. The nurses must know who is responsible for the machine maintenance and they need to call someone to fix your machine. There is only 1 other thing I can think of. This happened to me once. The acid line in the jug got a small pin hole, I couldn’t even see it. But what I could see was air in the acid line as the machine was drawing it in. Next time it happens look at both the bicarb line and the acid line and see if you see any air bubbles. If you see air the problem may be corrected by giving you a new top for the jug.

I know pushing the reset button on Tmp doesn’t seem to help much because you have to keep pushing it and pushing it but it would get you through a rinse back without having to do it manually. A pain for sure!

Marty thanks for the feedback. I don’t think it is the acid because I get very low on bicarb during the night. I have taken to doing 3 hour treatments during the day and if it were a hole in the acid tube wouldn’t it affect it during shorter treatments?
I will be going to Rogosin Monday and I’ll ask for a new tube to see if it makes a difference.

What dialysate flow are you running? When I was on the B Braun at home and got a low conductivity alarm I’d shake the Bicarb jug. Do you mix your own Bicarb?

Spiderwoman, Being low on the Bicarb isn’t your problem. I run dad 8 1/2 to 9 hrs and I have less than 1/2" in the jug when I take him off.
I understand what Bill is saying; if your bicarb hasn’t been mixed properly this can cause a conductivity alarm. I am guessing this isn’t it because; I can’t believe you would screw it up every night. It has been my experience that it can take bicarb as long as 3 hrs before it dissolves good. I usually draw my bicarb water in the morning and put the bicarb in at 4pm and start treatment around 9pm. This gives the water time to warm and plenty of time to shake the jug occassionally to make sure it has mixed well.
I am thinking if it were air you couldn’t run for 3hrs before an alarm but I don’t know for sure. But before you ask for a new top to the jug look at the lines you will see air bubbles if this is the problem. I am assuming you have turned your Sodium Variation on. Have you checked your filters in the wands to be sure they aren’t clogged? Were you shown how to connected a 30cc syringe with concentrate and inject it in the nozzle. Sometimes a small chunck of bicarb becomes lodged in the nozzle and restricts the flow. If you have ruled out these possibilites you need a service call on the machine.

and speaking of mixing bicarb, I have spent hours on it and have done it in very little time.
I have not been given any real training in how to do it with minimal effort. I have spent as long as 3 hours sifting, funneling, rocking it back and forth, I’ve tried mixing small batches, swinging it back and forth (a major effort but effective).
again, when I tell my trainer she says nobody takes more than half an hour.
when I did it yesterday it mixed amazingly well. I just flipped the jug from side to side an lo and behold! no sludge on the bottom.
but a friend from Australia tells me they get a liquid package from Fresenius and mixing is no big deal.
is it me or do we get punished here for having ESRD?

In regards to tmp, whenver there was a problem in center (with tmp) they couldn’t seem to figure out and would blame on mix or the machine, would pull a machine for tech. to fix.
I recently had a problem with tmp on my machine and no one could figure it out. One of the nurses who worked in dialysis a very long time came over to my machine and said it was running 'wet" with saline, and that would give a mis read on the tmp. She changed transducer cap and wiped chamber with alcohol prep and the tmp corrected.
Marty, thanks so much for helping Helen.
Helen, I hope things start going better for you, as I know you have put so much time and effort into training. Let me know how things are going! Lin.

Lin, you described what happened accurately. It’s what we call in short a wet transducer. I can tell you what happened. When the machine was set up someone forgot to clamp the med port or the transducer line. Thus when the saline was going through either for prime or recirculation it allowed the saline to reach the transducer by having the line open (unclamped).

Helen, Do stick with it. Experience is the best teacher. I have learn’t more when things went wrong than I did when things went right. This is my system on bicarb and I have never have a conductivity problem caused by my jug.
I fill the jug in the morning right after heat disinfect or chemical rinse. I cap it and let it sit. At 4pm I put the bicarb in recap it and lay it on it’s side on a counter. Every now and then as I see fit I walk by and give it a shake. When I go out to wash before setting up I give it the last shake and set it upright. This gives things a chance to settle. Then before I carry it into the machine I look inside to see if it is clear. When I go to put the venous tubing on the machine I take the cap off the jug and rinse it with my RO water to make sure nothing is clogged in the cap. I have found a ounce of prevention is worth a pound of cure.

Any news on the conductivity/bicarb issues? How are your treatments going?

I had a technician in to fix the machine but have not done an overnight yet. I did a 3 hour treatment yesterday and halfway through got a high conductivity alarm saying it was at 14.7. I shook the bottle and the conductivity started dropping. I got a low conductivity alarm at 13.1. shook the bottle again and it slowly rose to about 14.1 which is where I started out.
I have to call again because something isn’t right and I don’t think it is how I mix the bicarb.
anybody know about the liquid bicarb solutions they use in Australia instead of the powder we get. I heard it is a Fresenius solution and wonder why we are being punished by being deprived of it.

Spiderwoman, I would think it is the bicarb mix. Otherwise when you shook the jug the conductivity wouldn’t have changed. Shaking the jug affects the mix which looks like it caused the change. If after shaking the jug you didn’t get a change in conductivity then I think the problem would be elsewhere. I think we use a Baxter Mix for our Bicarb I’ll have to check. In 4 years I have never had a conductivity alarm do to a bad mix. The person who services our machine told me 98% of the time when patients have a conductivity problem it is the mix. Not trying to say your wrong just something to consider.

I found a company that sells liquid bicarb. I don’t know if your clinic would be willing to get this for you, but here’s a link to the product and you could show it to your home training nurse:

If you can find out the name of the solution from your Australian friend, perhaps your nurse could look for it online.

just want to update everyone that I have been doing nocturnal all week and haven’t had any low conductivity alarms. a technician was here last week and made some repairs.
Rogosin told me if I didn’t start nocturnal they would take me out of the program so I reluctantly started Sunday night, that plus the fact I had been too busy to dialyze earlier.
I did have some problems with arterial pressure alarms so I rotated my needle once and now do it when cannulating. I also hold my tubes in my hand all night and it seems to keep the alarms down to a minimum.