Top Tips: An Aquarius System PCRRT Workshop handbook

1. Practical Workshop

The workshop presents a primed Aquarius in recirculation mode. Each group will be supported to
practically connect and run a brief therapy simulation. 10 minute discussion on Troubleshooting -
common alarms (high and low priority), teaching appropriate observation skills and responses.

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pCRRT Aquarius Top Tips Workshop
 Top Tips: An Aquarius System PCRRT Workshop handbook
Alarm
Low Access Pressure
(Access pressure below the
lower alarm limit of 0 to -
250mmHg)
High Access Pressure
(Access pressure exceeeds
alarm limit of
between -50 and +200mmHg)
Cause Options for error removal Action
Blood flow is too low/blood pump Check blood flow rate. Restart the blood pump.
is off.
Consider increasing the blood
pump speed
Assess vascular catheter for Check patient access. Restart the blood pump.
occlusions/clots. Reposition the patient.
Access is against the vessel
wall.
Reposition the catheter and/or
line.
Swap the lumens over.
Consider aspirating the lumens.
Consider pulling the catheter
back.
Consider a new catheter.
Review anti-coagulation.
Rotate the blood pump ¼
anti-clockwise.
Access line is kinked/clamped. Remove the kink/unclamp the Restart the blood pump.
line
Tubing set is kinked close to Check access line, including Restart the blood pump.
access or pre-filter pressure access and pre-filter sensors, for
sensors. kinks or occlusions.
Prepare to end the therapy.
Consider anticoagulant and Restart the blood pump.
replacement fluid review.
Check patient access.
Reposition the patient.
Access is against the vessel wall.
Reposition the catheter and/or line.
Consider aspirating or swapping the
lumens.
Consider pulling the catheter back.
Consider a new catheter.
Review anti-coagulation.
Remove the kink/unclamp the line
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pCRRT Aquarius Top Tips Workshop
 Top Tips: An Aquarius System PCRRT Workshop handbook
Low return pressure
(Return pressure is below the
lower alarm limit of 20 to
200mmHg)
High Return Pressure
(Return pressure exceeds the
upper alarm limit of 120 to
300mmHg)
High pre filter pressure
(The pre filter pressure exceeds
the upper alarm limit of
400mmHg)
Blood flow rate is too low.
The blood pump has stopped.
Return line is disconnected.
Return line is kinked or clamped.
Return line is occluded or clotted.
Drip chamber is clotting.
Faulty return pressure transducer.
Check filter for signs of clotting
Blood flow is too low
Line is occluded
Clamps left on
Faulty pre filter pressure sensor.
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pCRRT Aquarius Top Tips Workshop
Consider increasing the blood Restart the blood pump.
pump speed.
Restart the blood pump.
Check vascular access
connections.
Remove the kink/unclamp the line. Restart the blood pump.
Reposition the line. Restart the blood pump.
Consider swapping the lumens
Consider anticoagulant and Restart the blood pump.
replacement fluid administration
review.
Ensure adequate blood level in the
drip chamber.
Prepare to end the therapy.
.
Possible faulty transducer Prepare to end treatment
Stop the treatment and
report the breakdown.
Access line is “kicking” Restart the blood pump.
Visible clots in the filter
Visible clots in return chamber
Check clotting
Consider Increasing pre-dilution
3 consecutive high pre filter
pressure alarms, consider ending
the treatment.
Ensure adequate blood flow.
Check line set for narrow sections
Check access line for kinks or
clamps.
Check pressure sensor
Top Tips: An Aquarius System PCRRT Workshop handbook
Air detected Air or micro-foam visible in the drip
chamber or Return line.
The return line is not properly
positioned in the air detector.
The blood level is too low in the drip
chamber.
Air detector sensors are dirty.
Marks on the return line.
Check all connections, including
access, filter and Heparin
connections for sources of air leaks.
Ensure both seals on the Accusol
bag/s are broken, bag/s are spiked,
all clamps are open, lines are not
trapped or kinked.
The air detector is faulty.
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PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Remove air from the drip chamber
and Return line.
Ensure Return line tubing is not
“pinched” within the air detector.
Raise the blood level in the drip
chamber.
Clean the sensors.
Ensure line is not pinched within the
air detector.
Ensure all connections are secure
and patent.
To remove air from the line:
Step1. Attach syringe to the
top of the return chamber
after carefully releasing the
pressure from the line.
Step 2. Press the “clamp
key” to open the return line
clamp.
Step 3. Remove all air from
the return chamber with the
syringe.
Step 4. Confirm the tubing
is correctly inserted into the
air detector
Step 5. If level in the drip
chamber is correct and the
bubbles are out of the
tubing, press the “clamp
key” to close the return line
clamp.
Step 6. Resume treatment
by pressing the blood pump
key.
Step 7. Monitor and control
the level in the drip
chamber
 Top Tips: An Aquarius System PCRRT Workshop handbook

Balance alarm Counted balance alarm:
Check substitution/dialysate
line The patient’s fluid balance
deviates more than 50 g in adult
treatment or 20 g in pediatric
Or
treatment for more than 15s.
The deviation is less than 120 g
Balance alarm
Check filtration/effluent line The deviation could not be
compensated during TFL
Review UF variation in More
screen.
All clamps are open.
Lines and bags are hanging
freely.
Lines and bags are not kinked,
clamped or blocked.
Bag connections are correct
Bags and lines are not resting on
the cart frame
Bags are not swinging.
Lines on the manifold are all
unclamped.
Accusol bags are spiked.
Seals are broken on the Accusol
bags.
Restart the treatment
Note: If 5 counted
balance alarms occurred
during the 20 minute
window period it will not
be possible to resume
the treatment. Follow the
onscreen instructions to
end the treatment.
If no further alarms are
shown for a period of 20
minutes, the balance
alarm counter will reset to
zero.

Ensure connections are secure

and fluid is not leaking from the
bags

Avoid touching the filtrate or

substitution bags while the
treatment is running.

Avoid adding or removing bags

while the therapy is running.
Avoid moving the Aquarius
system while the Balance system
is active.

Non counted balance alarm: Reduce the number of

The patient’s fluid balance
deviates more than 120 g for
more than 15 seconds.
substitution/dialysate bags
Bags are swinging on scales or
touching the cart frame of the
Aquarius.

When multiple bags are hung on

the scale, if the bags are touching
each other or the tubing lines are
resting on the cart frame, the
draining of the bags can cause
them to shift position, resulting in
a temporary weight change

A bag is detached from the scale.

Adding or removing a bag without

stopping the Balance system.

Moving the Aquarius system

while the balance system is
active.

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.

PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Top Tips: An Aquarius System PCRRT Workshop handbook
Alarm Cause
Blood Leak Blood leak chamber not filled with fluid.
During set up, the blood leak chamber
has been removed from its housing.
Dust on the mirror.
Mirror is cracked or missing.
Filter membrane is damaged / ruptured.
AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.
PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Options for error removal Action
During lining go to “reprime” and Restart the treatment.
choose ultrafiltrate line.
Ensure filtrate line is securely
connected.
Ensure there are no kinks/narrow
sections on the line.
Check lining within pump housing
Ensure there are no
scratches/marks on the chamber.
Reposition the blood leak
chamber.
Remove mirror.
Clean and replace as found.
Do not clean the infrared light.
It is not recommended to use a
mirror from another device.
Report the breakdown
Filtrate / plasma contains blood. Select Options and End
(Note: Ultrafiltrate typically is a treatment, follow the on-
rose colour) screen instructions to wash
Check BLD % reading in MORE back and end the treatment.
screen.
Consider doing a urine dipstick to
confirm the presence of blood.
Discontinue treatment and
change circuit.
 Top Tips: An Aquarius System PCRRT Workshop handbook

High TMP TMP has risen slowly – filter is Reduce post-dilution flow rate and Restart the treatment
(-50 to +450mmHg) clogging. increase pre-dilution flow rate.
Review anti-coagulation.
TMP has risen rapidly – filtrate line Check blood flow / exchange ratio.
or bags clamped or kinked. Increase blood flow rate accordingly. .

High TMP from the start of therapy Unclamp or remove kink from line.

Check blood flow / exchange ratio.

Increase blood flow rate accordingly.

Low TMP Filtrate pump runs slower than the Modify blood flow rate and/or fluid Restart the treatment
treatment pumps. exchange.

The filtrate line is closed between Check filtrate line is not kinked,
the filter/kidney and waste/effluent clamped or twisted. .
bag/s. Line is not “pinched” within the pump
housing.

Pressure test disabled Air detection system does not detect
“free air” in the tubing.
(The clamp and pressure test is disabled.)
Make sure that the return line Restart the pressure test.
does not contain air.
Make sure that the return line is
properly installed in the air
detector and that the air
detector is pushed in.

Ensure that the return line is not

scratched.

Re-prime the blood line.

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.

PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
 Top Tips: An Aquarius System PCRRT Workshop handbook
No fluid chamber detected
Check Degassing
Chamber
(Position: Short line towards the
back and long line at the front.)
The degassing chamber (ADU) is not
inserted.
The ADU worked for more than 25s
without detecting fluid in the chamber.
The hydrophobic filter on the ADU
sensor line is wet.
(Measured pressure < –ve 300 mmHg).
The system detects a positive pressure
higher than +30 mmHg.
Fluid is detected in the ADU sensor
line.
AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.
PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Ensure the ADU chamber is
sitting on the pressure
switch. (Black and red
switch)
Ensure the fixation clip is in
a horizontal position and
closed around the short
tubing of the ADU.
Check all clamps on the
substitution/dialysate line
are unclamped.
Check the
substitution/dialysate line is
not kinked.
If using a manifold ensure
lines are not clamped or
kinked.
Check if the frangible pins
on the bags are broken.
Ensure both seals on the
Accusol bag are broken.
Ensure lines are not
trapped under the heater
door. (Ensure heater coil is
positioned with the smooth
side against the heater plate
and the lines are in a horizontal
position.)
Use line tidies on the ADU
or integrated syringe driver
to position lines in order to
prevent kinking of the lines.
Ensure ADU is in the
correction position. (Short
line towards the back and long
line at the front.)
Restart the treatment
To remove fluid from the sensor
line (long line with green
clamp):
Step1: Clamp the line.
Step2: Disconnect line from the
sensor and hold the line up.
Step3: Attach a 10ml syringe,
unclamp the green clamp and
push air into the line until the
line is clear of any water.
Step4: Clamp the line again,
remove the syringe and attach
line to the sensor.
Step5: Lift the chamber up from
the pressure switch and push
the chamber down again.
Ensure the fixation plate is
pushed down around the short
tubing.
Step6: Unclamp the green
clamp.
Press the mute button (to reset
the alarm)
and restart the treatment.
 Top Tips: An Aquarius System PCRRT Workshop handbook

Change The substitution/dialysate bag/s are Change the bag/s. Restart the treatment
substitution/dialysate bag nearly empty (approx. 150mls left per bag)

OR
The filtrate bag has reached maximum
Change the bag/s
Change filtrate/effluent bag permissible weight

Check transducer The pressure domes have not detected Ensure the domes are Restart the treatment
connections any pressure change for 15 seconds. securely connected.
IMPORTANT: do not
remove any pressure
sensors during treatment.
If domes are in place,
consider increasing blood
pump or treatment pump
rates.

Turnover Failure
(Balance pump speeds are
consistently higher or lower than
the programmed speed for more
than 20 consecutive minutes to
ensure accurate fluid delivery.)
Fluid leaking from bags.
Incorrect line installation
Incorrect bag installation.
Pump calibration out of range
Ensure all connections are Restart the treatment.
securely attached and
patent.
Ensure lines are not kinked,
clamps are unclamped, and
lines are not twisted.
Bag/s is not spiked, spike or
frangible pin is blocking the
flow of fluid, bag/s is not
hanging freely, or bags are
swinging.

Report the breakdown.

Filter inappropriate for fluid delivery Consider using a different

rates. size filter.

Heater cools down
Balance system has stopped for more Ensure the balance system
than 15 s and the heater plate is active.
temperature is above 43°C.
The treatment is paused
until the temperature
returns to normal.
Active cool down management
may take up to 10 minutes. The
treatment will restart
automatically.

Substitution pumps will run

at a slow rate to help
cooling, taking priority over
Total Fluid Loss
compensation.

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.

PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
 Top Tips: An Aquarius System PCRRT Workshop handbook
System Test Failure
Heparin Pump
(Actual values of control and
protective systems are outside of
their limits.)
Less common Alarms.
Ensure both pump doors are closed Close the door/s. Press the blood pump to restart
the self test.
Ensure no bags are hanging on the Remove bag/s from the
scales. scales
If machine fails test again,
switch the machine off and
unplug from the wall. Leave the
machine for 15 minutes and put
the machine through self test
again.
If it still fails note the message
on the screen and report the
breakdown.
The plunger is incorrectly positioned. During Self test/Start up, If the error cannot be reset, put
ensure no line set is system out of operation and
installed notify technical support.
During treatment:
1. Check the heparin line is
not clamped.
2. Go to "Options" and
"Change Syringe", following
the on-screen text. Note: It
is NOT necessary to
remove the syringe during
this process
3. If problem persists,
program the pump to 0,
clamp the line and remove
the syringe.
Heparin driver is making a grinding Ensure Heparin line is not
sound clamped.
Whistling sound coming from the Ensure Heparin line is
Heparin line. clamped and capped if not
in use.
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PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
 Top Tips: An Aquarius System PCRRT Workshop handbook
No Bag
(Less than 45g are detected per
scale.)
Master key transfer
Keyboard Failure
Operation Mode
Blood Flow Failure The number of revolutions of the pump
exceeds or falls below the alarm limits
by ± 5%.
No bag/s on the waste/filtrate scale.
Bag weighs less than 45g.
Lines or the manifold is touching the
frame of the machine
Lines are twisted.
Filtrate line is clamped
Self test was performed with bag/s
hanging on the scales.
Number of bags programmed is
different from number of bag/s
actually hanging on the scales
A key press longer than 60 seconds
was detected
Short disturbances in the
communication between the master
and the controller CPU.
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PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Place bag/s on the scale. Restart the treatment pumps
Use a bag weighing more
than 45g. Note: It is not
recommended to re-use
used/empty Accusol bags.
Ensure lines and the
manifold is not touching the
frame of the machine.
Straighten/un-twist the line.
Unclamp the line.
Remove bag/s from the
scales and repeat the self
test
Use an additional bag on
each scale:
- Go to “Programming”
window.
- Program 2 bags.
- Ensure that 2 empty
effluent bags are
hanging on the filtration
scale and connect both
filtration bags to the
filtrate line.
- Ensure that 2
substitution bags are
hanging on the
substitution scale and
connect both substitution
bags to the
Programme correct number
of bags as per scale.
The alarms are to notify the Clear the alarms by pressing
user that an issue the blood pump key.
occurred).
If the alarms do not clear,
Report the breakdown.
Check the blood flow rate Press the blood pump to restart
the treatment.
Check blood pump tubing is
not twisted/pinched within
the pump housing
Check the tubing for narrow
sections/clamps
Top Tips: An Aquarius System PCRRT Workshop handbook

Notes:

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.

PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop
Top Tips: An Aquarius System PCRRT Workshop handbook

1. Citrate and Prostacyclin Anticoagulation

Discussion and demonstration.

Pre – course exercise: Please make notes on one of the following subjects

Consider the ‘state of the art’ for anticoagulation in your PICU: How do we choose Heparin,
No Anticoagulation or an alternative modality?

Citrate and Predilution, what we could learn from experience in Adult ICU, and where might
this lead our patient care?
The decision tree is a visual aid to map your thoughts

AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.

PM-0032-06/2015. Copyright 2015. All rights reserved.
pCRRT Aquarius Top Tips Workshop