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TRANSCRIPT
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SW 8.09.13
Training module 8 – HemoControlRef: Operator ’s Manual SW 8.09.13
Chapter 11: HemocontrolTM Biofeedback System
Dialysis System
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HemoControl• Enhances intradialytic hemodynamic stability
• Maintains sodium balance
• Facilitates dry weight accuracy
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HemoControl1
• Automatic profiling of- Dialysis fluid sodium concentration
- Ultrafiltration rate
• Based on- Patient prescription
- The actual Blood Volume changes measured by the Hemoscan system
1: Santoro et al.: Blood volume controlled hemodialysis, Kidney International, Vol 62, 2002;; pp. 1034-1045
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HemoControl guides the patient’s actual blood volume along a pre-defined trajectory
HemoControl
Actualblood volume
Ideal bloodvolume path
0
- 5%
- 10%
- 15%
- 20%
Time
Change in blood volume (%)
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• Provides on-screen information• Compares Hemocontrol information
to the set target values• Adjusts parameters (targets)
accordingly
HemoControl
Controlsystem
Set targets(Clinical prescription)
Patient
Monitoringsystem
UFV, BV, Na
UFV: UF volumeBV: Blood volumeNa: PrescribedSodium
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HemoControl Settings
Start by setting:• Treatment time• UF volume• Distribution volume
Patient individual average refill rate
Coefficient for calculation of “Max Initial UF”
Hemocontrol setting screen
Sodium conc. bandNarrow -5 to 10Standard -5 to 15Large -7 to 18
Equivalent plasma Na Set prescribed sodium equal to standard HD
The use of the Patient Card is recommended to simplify the settings of the HEMOCONTROL parameters
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Setting Final BV/UF Volume Ratio
• The Final BV/UF volume value is a measure of the patient’s average refill rate:- The lower the value (more negative), the lower average refill rate during the treatment
• A Final BV/UF volume of -2.5 %/L could be used as start value for most patients
Follow the trend and adjust Final BV/UF volume over time
-2.5
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Setting Max Initial UF by the UF Coeff
Max UF Coeff:• Is used for determining the Maximum Initial UF rate• Setting range 1.2 - 2.0• Max Initial UF rate = Max UF Coeff x UF volume/ trmttime- EX: Max Initial UF rate = 1.8 x 2.5 L/4h = 1.8 x 0,6 = 1.13 L/h- EX: Max Initial UF rate = 1.2 x 2,5 L/4h = 1.2 x 0,6 = 0.75 L/h
The Maximum Initial UF rate and the set UF rate provides the UF rate band used by HemoControl
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Setting Equivalent Na and Sodium Limits
• The Equivalent Na value should be equal to the Sodium value which would be set in a standard dialysis
• Setting range 135 – 150mmol/L• The Na Limits defines the band within the sodium in the dialysis fluid can
be modulated • The Equivalent Na actual range depends on the Na Limit band selected• Only bands compatible with Equivalent Na are available for
selection
Equivalent Na
Available Na Limits:• Narrow: -5 to 10 mmol/L• Standard: -5 to 15 mmol/L• Large: -7 to 18 mmol/L
Equivalent Na140
Treatment Time
StandardSodiummmol/L
135
155
The modulation of dialysis fluid Na concentration within the preset Sodium bands on Artis is further restricted to never exceed the conductivity range of 13.4 to 15.6 mS/cm
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Calculated Values
The HEMOCONTROL activation button is not availableuntil Treatment Time, UF Volume and Distribution Volume are set
Final BV = Final BV/UF volume x UFV
UFVTreatment Time
Max Initial UF = Max UF Coeff x
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HemoControl Activated
Hemoscan is automatically activated together with HemoControl
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Treatment Start
For changes affecting the BV during treatment, use the Stand-by button
Becomes available at treatment start
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HemoControl Stand-by
HemoControl stand-by is recommended when an IV infusion has to be administered to the patient that may affect the relative blood volume measurement
When the Stand-by button is activated:• The automatic profiling of the UF rate and Sodium parameters are suspended for 5 minutes
• Recommended values are applied i.e. the value to apply in order to reach the prescription paramenters (UF Volume and Equivalent Na)
• An on-going Diascan measurement will fail• The Stand-by is automatically deactivated after 5 minutes – it may be manually deactivated before that
Do not use HemoControl during a blood transfusion
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• Actual blood volume change (red line)• Values should stay within the blue lines
path
Diff. BV/UF
BV% and Accumulated UF Trend Graphs
• Accumulated UF (red line)• Values should stay within the blue line
path
On HC settings screen the graphs are updated from treatment start
Diff. BV/UF
For accurate measurements maintain QB >180 ml/min
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Dialysis Fluid [Na] and UFR GraphOn the Fluid screen graph, the dialysis fluid Sodium (Na) concentration and UF rate can be followed
Plasma Sodium Conductivity is displayed on the Diascan Settings screen and in the Event List
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Forecast Values
The forecast values are updated 45 minutes after treatment start, together with the:• The Difference in BV/UF cross graph on the HC setting screen • Hemocontrol plasma refilling indicator on the overview screen (next slide)
Diff.
Diff. UF
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Green area = On prescription
Yellow areas = Prescription may not be reached, attention needed
Orange areas = Prescription may not not be reached, action needed
Plasma Refilling Indicator
The arrow appears 45 minutes after treatment start
HemocontrolChart Panel
Arrow = Plasma refilling indicator
Blood Volume = Actual BV change
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The Difference in BV/UF Cross Graph• Difference in UF (y-axis)Indicates the accumulated UF Volume deviation related to set targets
• Difference in BV% (x-axis)Indicates the current BV change deviation related to set targets
Diff. UF
Diff.BV%
Diff. BV/UF
In the optimal case, the dot is in the absolute centrewhen the treatment time is achieved
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+-
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Interpretation of the Cross Graph
Q1(UR): Refilling rate better than expected;; opportunity to remove more water
Q2(UL): Unusual status;; if this status persists deactivate Hemocontrol
Q3(LL): Refilling rate lower than expected;; dry weight might not be achieved
Q4(LR): Refilling rate better than expected;; fluid removal restricted by Max Initial UF When the dot is in the yellow or the orange area, assess whether to wait for the dot to re-enter the green area on its
own or to adjust a treatment parameter
UL=Upper Left UR=Upper Right
LL=Lower Left LR=Lower Right
Q3 (LL) Q4 (LR)
Q2 (UL) Q1 (UR)
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Out of Limits – Upper Right Quadrant
If Blood Pressure or patient’s status is affectedIn case of minor symptoms:► Consider increasing Final BV by making it less negativeIf saline is administered:► Consider using Stand-by or deactivate HEMOCONTROL
Refilling rate better than expected• BV decreases less than expected• UFV increases more than expected
If Blood Pressure and patient’s status are not affected► Consider increasing the UFV - a value half way between Forecast and Final UFV may be used
► Consider increasing the Final BV if dry weight should be maintained- a value half way between Forecast and Final BV may be used
► Check Blood Pressure and patient status
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21© YEAR, Legal owner
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Out of Limits – Lower Right QuadrantUF volume may not be reached• BV decreases less than expected• UFV increases less than expected
► Check Blood Pressure and patient status
If Blood Pressure and patient’s status are not affected► If the BP is stable, consider increasing the Max Initial UF
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Out of Limits – Lower Left Quadrant
If Blood Pressure and patient’s status are notaffected
► If the dry weight should be maintained, consider decreasing the Final BV by making it more negative- A value half way between Forecast and Final BV may be used
If Blood Pressure or patient’s status is affectedIn case of minor symptom:► Consider decreasing the UF volume-A value half way between Forecast and Final UFVolume may be used
If saline is administered:► Consider using Stand-by or deactivate HemoControl
Refilling rate lower than expected• BV decreases more than expected• UFV increases less than expected
► Check Blood Pressure and patient status
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Out of Limits – Upper Left Quadrant
This is a contradictory situation following an adjustment of a settingSuggested action:If the dot persists in this quadrant for more than 15 minutes ► Deactivate HEMOCONTROL
Once deactivated, HEMOCONTROL cannot be activated again
Unusual Status• BV decreases more than expected• UFV increases more than expected
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Adjustments During Treatment
Rules of Thumb• Avoid adjusting more than one parameter at a time.
• A value half-way between Forecast and Final values may be used as guidance for any adjustment.
• It takes about 30 minutes before the full effect of any adjustment is visible. Be patient and do not change any other parameter during this time.
• In general no more than one adjustment should be necessary during the treatment.
• When the dot of the cross graph is in the lower left quadrant (i.e. poor refilling suspected), a stable Blood Pressure associated with high heart rate may indicate an approaching Blood Pressure drop.
• As an alternative to the observational phase, a Final BV / UF Volume value of -2.5 %/L could be used as a start value for most patients;; in this case, some adjustments during treatment may be required.
Follow the trend over time and consider patient prescriptionon a regular basis
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When to Adjust the PrescriptionUpper right quadrantConsider Final BV or UF volume prescription:• If adjustments are made in three or more consecutive treatments
• If the dot is repeatedly close to the tolerance limits when treatment time is completed
Lower right quadrantConsider Max UF Coeff. prescription:• If Max Initial UF is adjusted in more than three consecutive treatments
• If the dot is repeatedly close to the tolerance limits when treatment time is completed
Lower left quadrantConsider Final BV or UF volume prescription:• If adjustments are made in three or more consecutive treatments
• If the dot is repeatedly close to the tolerance limit when treatment time is completed
Consider the Max UF Coeff. if:
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Nice to Know
• HemoControl is not available for on-line HDF treatments.
• An initial value of Hgb above 14 g/dl may lead to a Hemoscanmeasure out of range and will force the deactivation of HemoControl (Hgb operating range: 6 to 16 g/dl)
• When the UF volume is reached, the notification “Fluid removal completed #53” is displayed;; if desired, the UF volume can be increased in the Fluid screen.
• At treatment end the Final BV may be ±3% and the Final UFV ±0.3L compared to the set values while the plasma indicator is still within the green area.
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Hands on Module 8- HemoControl treatment
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References
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1. Santoro et al.: Blood volume controlled hemodialysis, Kidney International, Vol 62, 2002;; pp. 1034-1045
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For the safe and proper use of the Artis Dialysis System refer to the Instructions for Use in the operator’s manual available by contacting customer support
Important: Please note that the SW change to 8.09.13 of this presentation doesnot change the content of the training of the Artis Dialysis System for users.
HemoControl and Hemoscan are Trademarks of Gambro AB. Gambro is an indirect subsidiary of Baxter International Inc.
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