[QUOTE=Bill Peckham;11274]Can you provide the rest of your treatment details? Amount of dialysate and blood pump speed. I was trying to figure this out - there may be a way just from the information given but I “git lost in the figuring”, I was coming up with a 200 Qb and 22 liters of dialysate.
I assume you’re making sure there is just a half inch of air at the top of the warmer bag when you set up the machine, is that amount of air the same when you see the #14 alarm?[/QUOTE]
Bill;
The blood pump speed is 200
dialysate rate= 2.8 (19.6 divided by 7 hours)
dialysate vol=19.6 (Hang 4ea 5 ltr bags of dialysate)
Runtime= appprox 7 hours (I calculate for 7 hours)
UF rate= 1.0 to 3.6
UF Vol= .7 to 25.2
FF= 24 to 26
When I bleed the air from the dialysate lines I get only two corners of air in the heater bag. and when the #14 alarm goes off the air trap in the heater is still the same two air pockets(ears in the corner)See NxStage User’s Guide manual page 6-27. picture #2… If you are getting 1/2" air accross the top. You need to bleed it a few seconds more until you get the dog ears… (air in the corners) then close the clamp and tighten the cap. Note: DO NOT Tighten the cap too tight. If you do, it might get not come off if you have to extract air from the heater bag… Had the problem once… the cap came off but so did part of the connector… Broke the darn thing… it seems as though the plastic is made that way… for when I called tech support they say that it is a common problem… Guess they use to have the opposite problem of connections coming apart so they change the plastic to (Polycarbonate) so they would not fall off to easily. Like everything in this world, from one extreem to the other. Cause I complained when I broke the second fitting and that is what tech support told me. I was concerned because my partner uses a cathater to do hemo dialysis. Boy am I careful not to tighten it too tight when I hook up the venus and arterial lines to her cathater… Hate to see a broken tip in the cathater. which means we have to go the emergency and get the cathater tips replaced if not replace the whole thing…
Using 19.6 L of dialysate over 7 hours gives a dialysate rate of 2.8/hour. Our machine will not run that slow without an ocacasional #14 alarm. By testing I found the lowest we could run without a #14 was 3.1 L/hour. The bottom rate on the spec sheet is 6.0 as I recall so nocturnal patients are running dialysate rates well below the design range. If you look closely at low rates you’ll see tiny bubbles dancing up and down where the dialysate goes into the cartridge. Sooner or later they set off the dialysate air sensor.
My reaction is why not increase to 25 L - run more dialysate faster. A Qb of 250 is still slow or you could try a FF of 33.
I’m going to be very interested in the data (if it ever comes out) that can show the impact on clearances when you chnage Qb and thereby change Qd. I’ve never seen any data where Qd was less than Qb. I would also like to see the data that shows the impact of changing FF, including having an FF out of the current allowed range.
For instance I would like to know what sort of clearance you’d get from a 60 L run at a Qb 350 and an FF of 80. I think that would be a pretty good 3.5 hour run.
[QUOTE=Mel;11279]Using 19.6 L of dialysate over 7 hours gives a dialysate rate of 2.8/hour. Our machine will not run that slow without an ocacasional #14 alarm. By testing I found the lowest we could run without a #14 was 3.1 L/hour. The bottom rate on the spec sheet is 6.0 as I recall so nocturnal patients are running dialysate rates well below the design range. If you look closely at low rates you’ll see tiny bubbles dancing up and down where the dialysate goes into the cartridge. Sooner or later they set off the dialysate air sensor.
Mel[/QUOTE]
Mel;
Good to hear that you are also seeing these bubbles in the dialysate line at the cartgidge. When the hemodialysis is comleted and you are only running UF do you get COLD??? AS no heated dialysate is circulating thru the dialyzer. What has worked for us has been to extract these bubbles before doing the tubing switching… By doing this and making sure that there is no air introduced into that line after the extraction when attaching the line to the heater. Have had fewer alarms and sometimes all night sleep…
Anyway even after running the machine at 3.5 rate for 1/2 hours the bubbles are still there. Do not think the pump rate is enough to pull these bubbles down the tubing out of the system. I will Call Scott at NxStage monday and see if they have anyother fixes… Check the cartridge after the treatment by tearing off the paper around the line with the green clamp(close the green clamp first before removing cartridge). Every time I check I find that there is air trapped in the line behind the reduction of the tubing… about 1" into the cartridge… Yet sometimes there is no 14 alarm… Maybe the bubble sensor is set to tight… Guess the design of the pump as it rotates causes back pressure that make the bubbles go in and out of the cartridge. Probably making the pump rotate faster or having a pump the have more rollers so there is no back pressure would pull the bubbles thru the system when it is priming…
My wife is the patient and so far she has not complained of cold after the dialysate runs out, but that happens at 4:00 AM or so and she is asleep. I’m trying to get approval in the direction that Bill suggested and increase the dialysate from 20 to 25 and FF from .20 to .25 which will let us cut the blood flow to about 200.
I haven’t looked at the cartridge following dialysis, but I suspect at somewhat higher speeds the tiny bubbles don’t ever accumulate at the air detector. I’ve talked to NxStage at some length about it and except for various steps to eliminate air in and around the warmer I don’t believe they have yet devised a solution. Short of a physical solution there might be some way to prime the dialysate line to purge it of air before starting dialysis. I thought about drawing air out of the cartridge with a syringe as you suggested, but have not tried it.
I doubt if the economics will allow raising the dialysate quantity a great deal. Based on the limited data I have I’m concerned the clearance is not as good as we are used to seeing on a Fresenius machine. On that machine we run at a FF of 1.5! Increasing the dialysate as noted above should provide some improvement.
Mel, are you talking about the actual dialysior as the cartridge?
If you are,we attach a syringe to the blue end and draw out the small/sometimes large bubbles. I than change the syringe just in case more bubbles appear. We were taught this.
Hope this helps.
Pat
[QUOTE=Leafsunbear;11148]Personaly this thread seems kinda counter productive. It sound like more of an attack on NxStage then anything. Sure it was mentioned that people have been happy with NxStage, but then to say that there are problems that are not being addressed by tech support or the training team. Sure sounds more like an attack on NxStage to me. I have been with NxStage since May this year. I have had problems with the equipment. These problems have been directly dealt with by tech support in an extremely timely fashion, as in on the phone the minute the problem occurs. I had a newer machine with the new nocturnal cartridges, at first. There were some #14 alarms that would not reset. After some trial and error, the cartridge was upgraded and the problem was fixed. While they were working on the upgrade I just used an older model cartridge for three days. Seems like they performed a stand up job in my book. I have encountered some other issues that they sent me a post paid box to send the faulty cartridges back to them. The training is very thorough at my clinic, six weeks worth of thorough. So I have to ask how is this thread valid? Has NxStage dropped the ball? My answer to that question is, not once for me. I would be interested in knowing why the person who posted on the other board can not get the answers they need from their nurses or from NxStage. For some reason I don’t think they are asking or they are not pleased with the responses they are getting. I myself am one of the hardest patients to deal with and I have no problems with the NxStage people. I tried to answer the #14 alarm post that was also on this board. I hope that helps someone, all though I am not sure it will.
LSB[/QUOTE]
LBS
This thread has been HELPFUL… and It is not an attach on NxStage… The nurses, nor has NxStage resolved this problem… I have asked and reported this problem to the clinic and they have checked with other clinics that are using NxStage for NOCTURNAL and none has reported any problem like I am experiencing… NxStage Tech support has really not responded with a solution that cures this problem with this machine(our machine)…So my problem must be an isolated problem. Tech Support suggestion of increasing the dialysate rate to 3.5 has not worked on this machine, Heard from Mel that he has been successful using this technique to avoid the #14 yel alarm. But by doing this the Ultrafiltration is done an hour or so after the hemodiallysis is done so NO HEATED DIALYSATE is circulating thru the dialyzer… Don’t know if you get cold while dializing on the NxStage but I have to put a lot of blankets on my partner to keep her warm. Although NxStage has a 1000 patients using the System One I bet the percentage that are Nocturnal is less than 5%. I have left this problem with them and hope they can figure a way to get the fluid pump to process the bubbles thru the cartridge. Cause I know when more people start using the System One for Nocturnal they will be swamped with this alarm. The nocturnal slower blood flow rate is more gentle and I believe it does a better job. After 5 years of nocturnal treatments (using Fresenius) my partner is living proof of how well this modality is.
Why do you feel that it is a KNOCK on NxStage when we the users of their product use forums like these to discuss our experiences and share our problems and solutions? Isn’t it the reason why we get on these discussions? Where else would you go? The web is such a powerful tool if used properly, so lets continue to help our community without questioning the capability of its users. I think any and all inputs are welcome responses for any poster…
Hemohelper;
My reason for having issue with this thread is it was started by a person who is not a patient and the information used was cut and paste from your post on another website. When dealing directly with you, I have no problems talking about issues with NxStage. I am still very surprised that NxStage hasn’t done something to fix your problem. I do believe you that you are having the issue. I am just not sure why NxStage has not sent you a new machine and taken yours for testing. This would be my suggestion to you though. Start asking them when they are going to get you a machine that works. Tell that you have been on the internet and compared your story with other patients. That something is wrong with the machine you have because no one else has this problem. I do believe that the boards are a good place to share information. I just feel that Heather wasn’t thinking when she started this thread. The way she words things seems to be attempting to bash NxStage. That is just my opinion though. I also prefer that people take the time to register their screen name. That way they can be accountable for what they post. Again just my opinion.
and yes I do getcold on any dialysis machine. I use a electric blanket in between my other blankets now and I still get cold at times. So yes I understand your problem.
LSB
Well Hemo Helper, I see your machine issue is not resolved yet. You first posted about it on Nov. 15, 06’ This is not at all surprising to me, because as I stated in a previous post, we have been through machine issues many, many times. It can take days, weeks, months or even yrs. to get the answer, sometimes. We know exactly how it goes- in-center one asks the nurses/techs and if they don’t know, next comes the machine tech, if he doesn’t know then it’s the company’s turn. At the same time, one gets on the boards to see if anyone else has had the same problem. The ironic thing is, when the solution finally does pop up, it is usually as simple as pie! Hope you get your solution by Christmas -know it would make a great Christmas present to be able to start the tx and go to sleep without being paranoid, for once, that those air bubbles are building up and are about to set off the #14 alarm…
[QUOTE=Mel;11279]Using 19.6 L of dialysate over 7 hours gives a dialysate rate of 2.8/hour. Our machine will not run that slow without an ocacasional #14 alarm. By testing I found the lowest we could run without a #14 was 3.1 L/hour. The bottom rate on the spec sheet is 6.0 as I recall so nocturnal patients are running dialysate rates well below the design range. If you look closely at low rates you’ll see tiny bubbles dancing up and down where the dialysate goes into the cartridge. Sooner or later they set off the dialysate air sensor.
Mel[/QUOTE]
Mel.
according to the spec sheet that comes with the cartridge it states that the dialysis rate shoud be 10-200 ml/min so the lowest rate would be 10 X 60 min divided by 1000=.6 ltr/hr… and max would be 200 X 60 divided by 1000 = 12 ltr/hr. Where are you getting the 6.0 number from??? So running AT 2.8 ltr/hr is well within the limits… I tried treatments using faster rates 3.5 but no such luck those bubbles that were there at stage #23 never gets pulled thru the lines and eventually they gather together in back of the reduction on the tubing and eventually set off the alarm… Those dancing bubbles in my machine is there to stay unless I extract them with a syringe before starting the treatment. The roller pump is set correctly as when I extract my bubbles with the syringe I see the tubing collaps and I can’t get the syringe’s plunger to go all the way back. If there were any air leaking back into the tubing I would be able to pull the plunger on the syringe all the way back. So the air is being trapped in the tubing between the pump and the cartridge inlet… above the sensor. I was trying to convince NxStage that they need to change the Firmware that does the prime and have it run the fluld pump faster and longer while not letting the blood pump run… this should solve the problem. Also in state 23 my machine fluid pump is running but set at 40. this is not fast enough to do anything to the bubbles.
By the way do you know what the default settings have been set on your machine by your center? What are your system settings for: #26 Prime timer--------------0 #27 Prime fluid pump rate ----100 #28 Prime UF pump rate ----- 40 #29 Prime blood pump rate —360 #30 Recirculation FP --------- 40 #31 Recirculation BP rate-----320
Were you trained to change the settings?
It is in the user guide for system one. APPENDIX A…
Thanks for your Input…
Guess I should bug NxStage and see what have they been trying to get rid of the bubbles in the dialysate line. I know extracting the bubbles before starting the treatment works… It is strange that some nights when I check the line before I go to sleep there is a chain of bubbles going in and out of the cartridge but no 14 alarm all night… Who’s complaining… No me…
[QUOTE=Mel;11285]My wife is the patient and so far she has not complained of cold after the dialysate runs out, but that happens at 4:00 AM or so and she is asleep. I’m trying to get approval in the direction that Bill suggested and increase the dialysate from 20 to 25 and FF from .20 to .25 which will let us cut the blood flow to about 200.
I haven’t looked at the cartridge following dialysis, but I suspect at somewhat higher speeds the tiny bubbles don’t ever accumulate at the air detector. I’ve talked to NxStage at some length about it and except for various steps to eliminate air in and around the warmer I don’t believe they have yet devised a solution. Short of a physical solution there might be some way to prime the dialysate line to purge it of air before starting dialysis. I thought about drawing air out of the cartridge with a syringe as you suggested, but have not tried it.
I doubt if the economics will allow raising the dialysate quantity a great deal. Based on the limited data I have I’m concerned the clearance is not as good as we are used to seeing on a Fresenius machine. On that machine we run at a FF of 1.5! Increasing the dialysate as noted above should provide some improvement.
Mel[/QUOTE]
Mel;
When we were in the center for training they came up with the formular of using 15 ltrs and FF of 20. We ran that way for a week and drew blood and compared it to what we were getting using the Fresenius. It wasn’t doing as good of a job so they had to increase the amount of fluid to 20 ltrs/tx and FF rate ended up being 25+… So when we did the 7 hour treatment in training before going home we had another blood test and it was about what we were getting using the Fresenius machine.
I thought that when one was doing nocturnal treatments the blood pump was set at 200. (Nocturnal=Slow, gentle dialysis) On the Fresenius we were running at 200 blood pump speed. on the NxStage we are still running blood rate of 200. What is your blood pump rate now??? What is great is on the Fresenius we were processing max 80 ltrs of blood per 7 hour treatment but with the NxStage we average 85+ ltrs/7hr tx. More blood processed I assume a better treatment (should be taking more toxins from the blood)??? This past two months her blood results are about the same as what we were getting before using NxStage… just her phosphorus is getting low and now having to take phoslo… I use to add phosphate to her Bicarbonate jug on the Fresenius. So I knew something had to be done about her phosphours when we started to use NxStage…
You should get with your center and see if you can increase the dialysate and do a blood test and see if it is getting better clearance for you guys.
What is point in this? If people who are using nxstage are having that many problems take it up with your center or with nxstage. Any machine set up is going to minor bugs.
I use nxstage and I’m looking forward to the new set up. From reading Pat and Ralph’s story it sounds like the new set will be a great time saver plus doing it at night. And you know how Gus and EPOMAN feel about nxstage.
bobeleanor[/QUOTE]
Bob;
WHAT IS THE PIONT???
If you have no interest in this subject I suggest that you not get on this thread and not be bothered with what others might want to share. So you feel that NxStage and your center has all the answers for your problems then don’t be surprised when one day you have a problem that they take a while to resolve…or can’t. This is not a perfect world. But it upsets me that you feel so negative about sharing problems and solutions. I can see you calling NxStage at 3am and expect them to have the answers to your #14 alarm. Because Nocturnal is not the mainstream way of using the System ONE. Then you might think Hey!!! weren’t there discussions about this problem???
or it could be other problems right here on this forum… Where did you read about it first… it wasn’t a bulletin put out by your center or NxStage… But right here where you feel discussions like problems is, IS A BIG WASTE OF TIME…
Bob, excuse me for venting my frustration but if you have too much time on your hands go wash the car again rather than get involved in our problems. and solutions we don’t need your negativity…
I will probably get kicked out of this forum after this reply but as I stated if you have no interest about the subject find something that interest you and not question others needs…
Sorry , and vent all you want. I did not know that nxstage had so many people now going into nocturnal. I thought it was still in center trails. And a few people who are home were being given the choice to try nocturnal.
Sorry , and vent all you want. I did not know that nxstage had so many people now going into nocturnal. I thought it was still in center trails. And a few people who are home were being given the choice to try nocturnal.
bobeleanor[/quote]
Wow, I’ve just been dutifully reading this bulletin for about a month and there is certainly one thing to be said about people on home hemo - we are a passionate bunch. Probably explains why we are on home hemo. Keep dialyzing for the prize! Erich
Hahaha, perhaps those of us who talk too much get to go home, har har har… (jokingly)
Seriously, I think sometimes we get a bit stressed out from coping from this routine that we have to do and I guess sometimes you have to vent a bit, like taking a race and trying to beat your frustrations…