Aquarius for Platinum Software version 6 - Operator+Manual - English

Aquarius

for Platinum Software version 6 Operator’s Manual

Indications The Edwards Lifesciences Aquarius System is indicated for continuous solute and/or fluid removal in patients with acute renal failure or fluid overload. The Edwards Lifesciences Aquarius system may also be used in Therapeutic Plasma Exchange (TPE) therapies. Additionally, the Edwards Lifesciences Aquarius system may be used in Hemoperfusion therapies (Hemoperfusion therapy is not approved in the USA). All therapies using the Aquarius System must be prescribed by and performed under the responsibility of a physician who is familiar and well informed about continuous renal replacement therapies.

Contraindications The Aquarius™ System is not designed, sold, or intended for use except as indicated. All generally applicable side effects and contraindications for extracorporeal therapies must be observed. The Aquarius™ System is not intended to be a substitute for monitoring the patient's condition or extracorporeal circuit by trained and qualified personnel. The Aquarius™ System is recommended for use only on patients whose prescriptions are within the minimum and maximum ranges of the instrument, especially for values of UF rate, UF rate error, dialysate flow range, blood pump speed, air detector sensitivity, and extracorporeal volume (as defined in blood set and filter labeling).

Warning! Read all warnings, precautions, and instructions carefully before use. Federal (U. S. A.) law restricts this device to sale by or on the order of a physician.

A Note to Users This Operating Manual provides instructions necessary for the proper operation of the Aquarius™ System. It is not a guide to the administration of the therapies provided. The safe and effective treatment using the Aquarius System depends primarily upon the medical skills and knowledge of the attending physician and nurses. Consequently, technical competence in operation of the Aquarius™ control unit must be supplemented by a thorough understanding of the associated medical procedures. Upon completing such training, the user must operate the Aquarius System in accordance with the information detailed in this manual. Patient treatment must be in accordance with specific procedures prescribed by a qualified physician. Aquarius is a trademark of Edwards Lifesciences.

© Copyright 2005 Edwards Lifesciences. All rights reserved.

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Table of Contents Indications ............................................................................................................................................................. ii Contraindications.................................................................................................................................................. ii Warning!................................................................................................................................................................. ii A Note to Users...................................................................................................................................................... ii 1.

How to Use This Manual ............................................................................................................................ 1 1.1. Organization ....................................................................................................................................... 1 1.2. Related publications .......................................................................................................................... 2 1.3. Symbols Used in this Manual............................................................................................................ 2 1.4. Abbreviations and Terms Used in this Manual................................................................................ 3 • Organizations.............................................................................................................................. 3 • Units of measure......................................................................................................................... 4 • Other expressions....................................................................................................................... 4

2.

GETTING STARTED WITH AQUARIUS...................................................................................................... 5 2.1. Setting Up ........................................................................................................................................... 5 2.2. Installation .......................................................................................................................................... 5 2.3. Equipment: Disposables and Consumables.................................................................................... 5 2.4. Waste Management............................................................................................................................ 6 2.5. Materials Used .................................................................................................................................... 6 2.6. Transport and Storage ....................................................................................................................... 6 2.7. Packing................................................................................................................................................ 7 2.8. Service................................................................................................................................................. 7 2.9. Set time and date................................................................................................................................ 7

3.

INTRODUCING AQUARIUS ........................................................................................................................ 9 3.1. General Machine Description ............................................................................................................ 9 3.2. Proper Usage / Fields of Application.............................................................................................. 13 • SCUF (Slow Continuous Ultra-filtration):................................................................................... 13 • CVVH (Continuous Veno-Venous Hemofiltration):.................................................................... 13 • CVVHD (Continuous Veno-Venous Hemodialysis):................................................................. 14 • CVVHDF (Continuous Veno-Venous Hemodiafiltration): .......................................................... 14 • TPE (Therapeutic Plasma Exchange):...................................................................................... 15 • Hemoperfusion (Blood Detoxification):...................................................................................... 15 3.3. Labelling............................................................................................................................................ 16 3.4. Side Effects, Contraindications ...................................................................................................... 17 3.5. Safety Instructions and Warnings .................................................................................................. 17

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3.6. Operational Sequence (Modes)....................................................................................................... 19 • System test ............................................................................................................................... 19 • System test failed...................................................................................................................... 19 • Preparation ............................................................................................................................... 19 • Priming...................................................................................................................................... 20 • Clamp & Pressure Test............................................................................................................. 20 • Recirculation ............................................................................................................................. 20 • Connecting the Patient.............................................................................................................. 20 • Treatment ................................................................................................................................. 20 • Disconnecting the Patient ......................................................................................................... 21 • Terminating the Treatment........................................................................................................ 21 3.7. Operating Concept ........................................................................................................................... 21 3.8. Safety Concept ................................................................................................................................. 23 4.

Performing a Treatment with AQUARIUS ............................................................................................... 25 4.1. Preparing AQUARIUS....................................................................................................................... 25 4.2. Priming mode - Priming the AQUARIUS....................................................................................... 35 4.3. Automatic degassing unit priming and use................................................................................... 39 4.4. Clamp and pressure test.................................................................................................................. 43 4.5. Recirculation mode - Recirculating saline solution ..................................................................... 44 4.6. Programming - Entering Patient Parameters ................................................................................ 46 4.7. Start Connection - Connecting the Patient .................................................................................... 47 • Single connection...................................................................................................................... 47 • Double connection .................................................................................................................... 49 4.8. Treatment mode - Description of functions throughout Treatment............................................ 51 4.9. Access Disconnection and Return Disconnection - Disconnecting the Patient ....................... 62 4.10. Treatment end - End of Treatment ................................................................................................ 64 4.11. AQUARIUS Therapies Choices ....................................................................................................... 67 • SCUF (Slow continuous ultrafiltration) ...................................................................................... 68 • CVVH (Continuous veno-venous hemofiltration) ...................................................................... 69 • CVVHD (Continuous veno-venous hemodialysis)..................................................................... 71 • CVVHDF (Continuous veno-venous hemodiafiltration)............................................................. 72 • TPE (Therapeutic plasma exchange)........................................................................................ 73 • Hemoperfusion.......................................................................................................................... 74

5.

AQUARIUS Alarms and Messages .......................................................................................................... 75 5.1. Description of Alarm Operation ...................................................................................................... 75 5.2. Alarms, Messages, System Errors, and Removal Options........................................................... 76 • Alarms....................................................................................................................................... 76 • Messages ................................................................................................................................. 78 • System Errors ........................................................................................................................... 80

6.

AQUARIUS Technical Data ...................................................................................................................... 83 6.1. Dimensions and Weight................................................................................................................... 83 6.2. Electrical Power Supply................................................................................................................... 83

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6.3. Electrical Safety................................................................................................................................ 83 6.4. Power Outage Operation ................................................................................................................. 84 6.5. Technical Data of Individual Components ..................................................................................... 84 7.

Guidance and manufacturer declaration – Electromagnetic emissions.............................................. 87 7.1. Safety rules – Electromagnetic Compatibility................................................................................ 87 7.2. Guidance and Manufacturer declaration – Electromagnetic emissions and immunity ............. 87

8.

AQUARIUS Cleaning and Disinfection.................................................................................................... 91 8.1. Cleaning ............................................................................................................................................ 91 8.2. Disinfection....................................................................................................................................... 91

9.

AQUARIUS Warranty and Liability .......................................................................................................... 92

10.

References ................................................................................................................................................ 93

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1.

1.1.

How to Use This Manual WARNING:

The Aquarius System must only be operated in accordance with the procedures contained in this manual, by trained and qualified personnel. The use of operating procedures, maintenance procedures, or accessory devices other than those published or recommended by the manufacturer can result in patient injury or death

Caution:

Federal (US) law restricts this device to sale by, or on the order of a physician.

Organization The material in this manual is organized in 10 sections Section Title

Content

How to Use this Manual

This section describes the organization and content of this manual.

Getting Started with Aquarius

This section provides the precautions and instructions needed to setup the Aquarius Control Unit.

Introducing Aquarius

Using the manual and describes the Aquarius instrument. Here you will find the steps necessary to turn on the Aquarius System; perform treatment and end treatment. The alarms and messages generated by the Aquarius System are described. Each alarm’s potential cause and corrective action is listed here.

Performing a Treatment with Aquarius Aquarius Alarms and Messages Aquarius Technical Data

The Aquarius System’s technical specifications are listed in this section.

Guideline and manufacturer declarationElectromagnetic emissions

Compliance with EMC norms of this Aquarius version are described in this section.

Aquarius Cleaning and Disinfection

Cleaning and disinfection instructions are listed here for the Aquarius System.

Aquarius Warranty and Liability

Information related to warranty and liability are described in this section.

References

References used to generate this document

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1.2.

Related publications Aquarius System Service Manual : Information on the configuration of the instrument, testing and calibration of all systems (including safety systems), required periodic maintenance, necessary diagrams and replacement parts are all contained in the Service Manual. To determine if a more recent version of the System Service Manual is available, contact your service representative. Newer versions will have code number greater than 6.00.99 for the software version. To determine if a more recent version of the Aquarius Operating Manual is available, contact your service representative.

1.3.

Symbols Used in this Manual When step-by-step instructions are being given, the left column on the page is used for the step number. Otherwise, you may see one of the following symbols. This symbol indicates that the text to the right of it is background information you will need to fully understand the procedures that follow.

This symbol indicates supplementary information.

This symbol is used to draw your attention to a “Caution”. “Cautions” are used to indicate situations that may be hazardous to the equipment being used.

This symbol is used to draw your attention to a “Warning”. “Warnings” are used to indicate situations that may be hazardous to a person, either a patient or other personnel. This symbol is used in graphics to call your attention to the part of the graphic referred to in the accompanying text. If it includes a number, the number refers to the step or sub-step number in the text.

Symbols Used on/in the Aquarius Instrument Consult accompanying documents. Read all instructions before using. Caution: Consult accompanying documents. Read all instructions before using. Warning: Consult accompanying documents. Read all instructions before using. Mute Reset Air Detector / Venous Clamp Balance On/Off

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Blood Pump On/Off Filtrate Scale

(Yellow Dot)

Substitution Scale (Green Dot) ∼

Alternating current Potential Bonding Conductor Protective Conductor Degree of protection against shock: Type B.

Date of manufacture: year 2005 Manufacturer

Separate collection for electrical and electronic equipment

Product conforms to a particular directive of the European Union (European Medical Device Directive 93/42/EEC) Indicates compliance with both Canadian and U.S. requirements with respect to electrical shock, fire, and mechanical hazards in accordance with UL 2601-1 5R78. Humidity range for transportation and storage of product (non-condensing)

Temperature range for transportation and storage of product

1.4.

Abbreviations and Terms Used in this Manual • Organizations Abbreviation

Definition

AAMI

Association for the Advancement of Medical Instrumentation

CE CSA TÜV

Conformité Européenne. This designation indicates that a product conforms to a particular directive of the European Union. Canadian Standards Association. This designation indicates that a product conforms to the standards of the Canadian Standards Association. Technische Überwachungs-Vereine (Testing laboratories)

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•

•

UL

Underwriters’ Laboratories. This designation indicates that a product conforms to the standards set by Underwriters’ Laboratories.

U.S.A.

United States of America

Units of measure Abbreviation

Definition

°C

Degrees Celsius

cm

Centimeters

°F

Degrees Fahrenheit

kg

Kilogram

L

Liter

mL/h

Milliliters per hour

mL/min

Milliliters per minute

Other expressions Expression

Definition

Access

The tubing line supplying blood from the patient.

CRRT

Continuous renal replacement therapies

CVVH

Continuous venovenous hemofiltration

CVVHD

Continuous venovenous hemodialysis

CVVHDF

Continuous venovenous hemodiafiltration

EP

European Pharmacopoeia

FFP

Fresh Frozen Plasma

Hemoperfusion

Blood filtration using adsorption

IV

Intravenous

KUf

Ultrafiltration coefficient

Operator

Trained medical personnel using Aquarius.

Return

The tubing line returning blood to the patient.

SCUF

Slow continuous ultrafiltration

TMP

Transmembrane pressure

TPE

Therapeutic Plasma Exchange

Turnover rate

The sum of the programmed Loss rate, the Predilution, and the Postdilution substitution fluid rates.

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2.

GETTING STARTED WITH AQUARIUS

2.1.

Setting Up Personnel authorised by the manufacturer must perform set up and installation of the AQUARIUS system, according to the requirements. When setting up the AQUARIUS system, the room and the necessary power installations must comply with the currently valid standards. Line voltage must conform to the data specified on the data plate of the AQUARIUS system. Before putting the AQUARIUS system into operation carefully read the complete operating manual.

2.2.

Installation Before operating the AQUARIUS system for the first time, ensure that the system is complete and that all parts have been delivered with it. If the AQUARIUS system is damaged, do not put it into operation. In this case, notify the service technician responsible for this system. The AQUARIUS system may only be set up and installed by qualified staff authorized by the manufacturer. Authorized staff together with the prescribing physician may do basic modifications of particular settings that do not change the safety concept of the AQUARIUS system.

2.3.

Equipment: Disposables and Consumables The AQUARIUS system is designed to operate exclusively with the standard disposables and consumables intended for the indicated treatments. Follow the instructions for use provided by the manufacturer. Warning: Use only the tubing sets stated below to ensure the proper operation of the AQUARIUS system.

Item

Description

Manufacturer

Tubing set

Code: AQUALINE Adult Standard line set Extracorporeal volume (Blood circuit) = 100 ml Code AqualineS Pediatric line set Extracorporeal volume (Blood circuit)= 64 ml

Haemotronic

Tubing set

Haemotronic

Hemofilters, plasma filters, hemoperfusion cartridges and solutions to be used with the AQUARIUS system must conform to applicable standards. Use only products with blood port connections compatible with ISO 594 (Part 1+2) female Luer lock connectors, and connections of dialysate, filtrate and plasma ports compatible with male Luer lock connectors. Use catheters according to the instructions provided by the manufacturer; the catheter connector has to be compatible with male Luer locks.

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Use only hemofilters that are CE marked, according to the Medical Device Directive (93/42/EWG) and are registered for the indications CVVH, CVVHD and CVVHDF. For hemofilters do not exceed a maximum pressure of 400 mmHg to avoid pre-filter pressure alarms. Maximum TMP is 400 mmHg. Caution:

Risk of plasma filter damage. For plasma filters do not exceed a pressure of 100 mmHg .This alarm limit is preset in TPE therapy mode.

Warning !

Replacement solutions and dialysate have to be sterile and must meet PH. Eur. requirements. Use only 4.5 litres or 5 litres bags with female Luer lock connectors or a sterile adapter to male Luer lock. In the U.S.A.,dialysate should conform to AMMI Standard RD5. If a commercially available replacement solution is used, it must labelled intended for intravenous injection. The prescribing physician must define concentration and composition requirements.

Caution:

Never use solutions of different compositions simultaneously with the AQUARIUS system!

For information on disposables and consumables supplied and recommended by Edwards Lifesciences please contact your Official Representative or call its Customer Service.

2.4.

Waste Management The AQUARIUS system and used disposables should be disposed of according to the local provisions. The system must be cleaned before disposal to prevent biohazardous risks. Electronic components of the AQUARIUS system must be disposed of, according to currently valid regulations for the disposal of electronic components. For more information on disposal please contact: Edwards Lifesciences Services GmbH Edisonstr. 6 85716 Unterschleißheim Germany

2.5.

Materials Used The patient's blood does not have contact with the components of the AQUARIUS system, thus there is no danger of infection for patients, operators or other persons dealing with the system and there are no special requirements regarding the biocompatibility of the materials used for manufacturing this system. All tubing sets through which blood circulates, must be discarded after each use. This is also true for the integrated transducers that separate and protect the pressure sensors of the AQUARIUS system by means of an impermeable membrane.

2.6.

Transport and Storage To move or transport the AQUARIUS system it is necessary to release the locking tabs on the wheels. The AQUARIUS can then be rotated and freely moved about.

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To move the AQUARIUS system over steps or stairs the locking tabs must be released. The system should be tilted, lifted, and carried by at least three people. Never carry the AQUARIUS system holding on to the display, the I. V. pole, or the scale.

The AQUARIUS system must not be pushed over uneven floors. The following environmental conditions are required when storing and transporting the AQUARIUS system: Relative humidity: 30 to 80%, non-condensing Ambient temperature: -5 to +45°C (23 to 113°F) Ambient air pressure: 50 to 105 kPa The AQUARIUS system must be stored in a room with good ventilation facilities and little temperature variation.

2.7.

Packing Within the land where AQUARIUS is manufactured the system will be mounted and fixed and carried on special pallets. For special shipments, a box bearing all safety-relevant labels will be used.

2.8.

Service The AQUARIUS system is subject to technical safety checks and maintenance between 6 month and 12 month intervals. Only qualified service staff, authorized by the manufacturer, must carry out this maintenance and any other repair work. Any work done by non-qualified and non-authorized personnel immediately voids all warranties. Warning! Disconnect supply cord before servicing the Aquarius instrument.

More detailed information on the safety check and maintenance can be obtained from Edwards Lifesciences Technical Service.

2.9.

Set time and date

When help screen is opened, it is possible to set time and date by selecting Set date and time key.

1

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Turn selector button highlighted.

to see set time and date key

to validate. Press selector button Select value to be changed by turning the selector button until the value key is highlighted. Press selector button Press the selector button its target.

to validate. when the value reaches

Turn the selector button to select another value to be changed if necessary, or select Exit clock mode key to go back to the help screen.

2 Accessible values for change are: For time: Hour Minute Second For date: Day Month Year

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3.

INTRODUCING AQUARIUS

3.1.

General Machine Description The AQUARIUS system is an Automated Fluid Balance Monitor, designed to be used with various extracorporeal treatments in the field of renal replacement therapies or plasma therapies. All therapies must be prescribed by a physician. The AQUARIUS system is divided into three circuits: the extracorporeal (blood) circuit , the substitution/dialysate circuit and the filtrate circuit. Toxic substances are removed by filters and clean blood is returned to the patient. The AQUARIUS system uses two scales to accurately measure and precisely balance filtration and substitution volumes. Anticoagulant may be supplied to the extracorporeal circuit via an anticoagulant pump. The prescribing physician may select continuous or intermittent options. The AQUARIUS protective system is designed as a 2-channel system to protect the patient from foreseeable danger. At the back of the scale system there is mounted a removable hand-crank. This can be used to manually turn the blood pump in case a pump stops. For future applications the machine has two ports on the rear where a datalog box can be connected to facilitate a data transfer of patient or machine data.

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AQUARIUS Front view

I. V. pole

Display Pressure sensor: Prefilter pressure

Postdilution pump

Blood pump Filtrate pump

Predilution pump

Pressure sensor: Filtrate pressure

Return line chamber Degassing chamber (Temp. Sensor)

Filter

Air detector Pressure sensor: Return pressure

Return line clamp Heparin pump

Pressure sensor: Access pressure

Substitution fluid scale

Filtration fluid scale Wheeled base

Locking wheels Brakes

Figure 1

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AQUARIUS Side View (Left)

Blood leak detector Power supply and power switch

Balancing scales

Figure 2

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AQUARIUS Side View (Right)

ON/OFF key

Lever for opening heating unit door

Heating unit door

Figure 3

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3.2.

Proper Usage / Fields of Application The AQUARIUS system is an Automated Fluid Balance Monitor. It is only designed for use with the treatments described in the following. It may only be operated within the given specifications and limits detailed in the manual.

•

SCUF (Slow Continuous Ultra-filtration): During Slow Continuous Ultra-filtration blood is driven through a highly permeable hemofilter via an extracorporeal circuit. SCUF is used primarily to manage fluid overload. The principle of clearance is Convection. Fluid removal is controlled and balanced by the filtrate pump and the scales. The filtrate is not replaced by substitution solution.

Figure 4

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CVVH (Continuous Veno-Venous Hemofiltration): During Continuous Veno-Venous Hemofiltration, blood is driven through a highly permeable hemofilter via an extracorporeal circuit. Sterile, physiological substitution solution is infused into the blood circuit before or after the filter (pre-dilution or post-dilution respectively) and filtrate is removed simultaneously, at an equal or greater rate. CVVH is used to achieve solute removal (small and medium-sized molecules) and fluid balance. The principle of clearance is Convection. The substitution solutions and the filtrate are controlled and balanced by the substitution pumps, filtrate pump, and the scales.

Figure 5 Warning!

All substitution used must be labelled for intravenous injection, of appropriate composition and prescribed by a physician. Use of incorrect or outdated solutions can result in a patient hazard. Page 13 of 93

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CVVHD (Continuous Veno-Venous Hemodialysis): During Continuous Veno-Venous Hemodialysis, blood is driven through a highly permeable filter via an extracorporeal circuit. Dialysate solution flows through the dialysate compartment of the filter, counter-current to the blood flow. CVVHD is used to achieve solute removal (small molecules) and fluid balance. Filtrate should correspond to the desired net weight loss. No substitution solution is used. The principle of clearance is Diffusion. The dialysate solution and the filtrate are controlled by the substitution pumps (Pre-dilution pump is dialysate pump), filtrate pump and the scales.

Figure 6

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CVVHDF (Continuous Veno-Venous Hemodiafiltration): During Continuous Veno-Venous Hemodiafiltration, blood is driven through a highly permeable hemofilter via an extracorporeal blood circuit. Sterile, physiological substitution solution is infused into the blood circuit after the filter . Filtrate is removed, simultaneously, at an equal or greater rate. Dialysate solution flows through the dialysate compartment of the filter, counter-current to the blood flow. CVVHDF is used to achieve solute removal (small and medium-sized molecules) and fluid balance. The principles of clearance are Convection and Diffusion. The substitution solutions, dialysate solutions and the filtrate are controlled and balanced by the substitution pumps (Pre-dilution pump is dialysate pump), filtrate pump, and the scales.

Figure 7 Warning!

All substitution used must be labelled for intravenous injection, of appropriate composition and prescribed by a physician. Use of incorrect or outdated solutions can result in a patient hazard.

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•

TPE (Therapeutic Plasma Exchange): During TPE blood is driven through a plasma filter via an extracorporeal blood circuit. Plasma is separated from the rest of the blood components and replaced by albumins or FFP (Fresh Frozen Plasma). TPE is used to achieve the removal of toxic substances (large molecules). Fluid balance usually remains unchanged. The plasma exchange is controlled and balanced by the substitution pump, filtrate pump, and the scales.

Figure 8

•

Hemoperfusion (Blood Detoxification): The Hemoperfusion therapy has NOT been cleared for Aquarius instruments sold in the U.S.A. The Hemoperfusion selection will be disabled for Aquarius sold in the U.S.A. During hemoperfusion blood is driven through a hemoperfusion cartridge via an extracorporeal circuit. Hemoperfusion is intended to remove toxic substances from the blood using a hemoperfusion cartridge. The principle of clearance is Adsorption. Fluid removal or substitution solutions are not used.

Figure 9 When using the special tubing sets and filters, cartridges, and solutions be sure to follow the instructions of the respective manufacturers.

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3.3.

Labelling The following labels are on the AQUARIUS system:

I.

Data plate Date of manufacture

Serial No. AQUARIUS Authorized Representative

115/230 V ~

Filtrate scale

4,4/2,2A Edwards Lifesciences LLC Irvine, CA 92614 USA

Edwards Lifesciences Services GmbH D-85716 Unterschleißheim Germany

Separate collection for electrical and electronic equipment II.

60/50 Hz

III.

The Filtrate scale is marked yellow.

230V:

Follow instructions Type of machine B

Substitution fluid scale

The substitution fluid scale is marked green.

Yellow

IV.

Manufacturer

Green

Fuses 2 x T 3,15 A

115V:

V.

Potential bonding conductor

VII.

Package labeling

2 x mT 4 A VI.

Protective conductor

Up

Fragile

Keep dry

CE mark

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3.4.

Side Effects, Contraindications All generally applicable side effects and contraindications for extracorporeal therapies must be observed. There are no special side effects or contraindications known for the described therapies at present.

3.5.

Safety Instructions and Warnings This summary does not contain all the safety statements in this manual. Other advisories, cautions, and warnings are included within the manual text. The Hemoperfusion therapy selection has been disabled for Aquarius instruments sold in the U.S.A.

Only personnel authorized by the manufacturer or special trained staff must perform set up, installation and use of the AQUARIUS system, according to the requirements. During the system test the operator must wait for the generation of the visual and audible alarm signals. If there are errors during the initial functional system test the AQUARIUS system must not be used. Refer to onscreen help and repeat. Notify the technical support if system test continues to fail on the same error. When bypassing one or more of the safety controls the operator is responsible for monitoring the patient. If power is restored after a power outage the operator is responsible for monitoring the patient. When entering the parameters the operator must compare the entered value with the displayed value. The patient parameters must be entered and adjusted in accordance with the instructions of the prescribing physician. Ensure that the patient blood access (usually a central venous catheter) is secured properly. Connecting or disconnecting the patient to or from the AQUARIUS system requires aseptic technique and continuous monitoring to prevent air from entering the system (air infusion) or blood from escaping from the system (blood loss). All system connections must be checked at regular intervals. All blood and fluid paths are sterile and non-pyrogenic. Connecting additional devices may result in exceeding the permissible leakage currents. If the system is used in parallel operations (according to open heart surgery standards), the equipotential bonding conductor must be connected. The AQUARIUS system may only be plugged into a properly installed grounded safety power outlet. Do not operate devices emitting electromagnetic waves near the AQUARIUS system. e.g. cellular phones. Do not operate the Aquarius system close to areas where explosive gasses or flammable anesthetics are being or have been used. The AQUARIUS system must not be operated simultaneously with high frequency surgery systems.

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The return pressure transducer ensures protection from extra-corporeal blood loss. If the pressure drops below the set pressure frame or the absolute pressure limit of 10 mmHg the blood pump stops and the return line clamp closes. Thus, the AQUARIUS system switches immediately to the safety mode. All solutions used must be sterile, of appropriate composition and prescribed by a physician. Use of incorrect solutions can result in patient injury or death. If a commercially available replacement solution is used, it must be labelled as intended for intravenous injection. The operator must ensure that the correct substitution solutions and dialysate solutions prescribed by a physician, are used appropriately for all therapies. In the U.S.A., dialysate should conform to AAMI Standard RD5 Solutions of different compositions must not be used simultaneously on the AQUARIUS system. It is recommended that the filters and the AQUARIUS tubing sets be changed after 24 hours of use. The Aqualine tubing set (adult) has been tested under the following high end conditions. This suggests the set may be used for up to 72 hours without adverse effect. Testing conditions: Duration = 72 hrs Pre-filter pressure = 450-500 mmHg Post filter pressure = 300-350 mmHg Blood flow = 450 ml/minute Infusion flow = 10 l/h Temperature = 37°C The AqualineS tubing set (Pediatric) has been tested under the following high end conditions. This suggests the set may be used for up to 72 hours without adverse effect. Testing conditions: Duration = 72 hrs Pre-filter pressure = 450-500 mmHg Post filter pressure = 300-350 mmHg Blood flow = 200 ml/minute Infusion flow = 10 l/h Temperature = 37°C A physician must prescribe the anticoagulant application. Important: The anticoagulant pump is designed for heparin only. Only use anticoagulants that comply with the requirements of national drugs regulations. The operator must make sure that the anticoagulant syringe used has been configured in service mode by a technician. Use only Luer-lock syringes. When “No anticoagulant” is selected, TMP and Pressure Drop monitoring pressures require a regular control in order to avoid or reduce any clotting risk of the complete tubing set (filter and lines). The operator must make sure that the pressure transducers integrated in the tubing sets are clipped on properly to the pressure sensors on the AQUARIUS system. Do NOT remove the pressure transducers during treatment. Before removing Aqualine or disconnecting dome after ending treatment, make sure that pressure level inside tubes are below 400 mmHg. End treatment screen display all four pressures from the system. Use a syringe to decrease pressure level before removing dome from pressure sensor. When domes are removed from pressure sensors over pressure conditions, there is high risk of burst and leakage of dome membranes. Negative ultrafiltration: Excessive negative ultrafiltration (a positive balance) may result in patient hazard. The prescribing physician must make this indication.

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This version of the AQUARIUS system (Platinum) is intended for use in the treatment of adults. When pediatric treatment is used, the patient must be physiologically capable to accept the minimum extra-corporeal blood flow of 10 ml/min. The I.V. pole may only carry a maximum weight of 2.5 kg. If for some reasons the user interface is compromised, the machine will normally stop automatically. In rare instances the machine will however continue even with a Black screen (for example if the back light is broken) In such instances the machine should be stopped manually, and the blood returned to the patient. This is possible by removing the return tube from the venous clamp and manually turning the blood pump with the hand-crank. The handcrank is located at the back of the scale system. Electrically isolated peristaltic pumps such as those used on the Aquarius System can produce electrostatic charges in the disposable set that are not hazardous to the patient, but can appear as an artefact on cardiac monitors. When starting treatment, observe the cardiac monitor before and after starting the Blood pump to verify that the artefact is not present. When “No anticoagulant” is selected, TMP and Pressure Drop monitoring pressures require a regular control in order to avoid or reduce any clotting risk of the complete tubing set (filter and lines).

3.6.

Operational Sequence (Modes) The operational sequence for the AQUARIUS system is fixed. It is impossible for the operator to accidentally change the sequence.

•

System test When the power is switched on, the AQUARIUS system is initialised. A system test is performed to verify the system´s main functions. The system test must be performed before the tubing set is attached to the machine. The current software version is displayed during the test.

•

System test failed The system test must be repeated if it fails. The onscreen Help function will provide further information to assist with troubleshooting any failure. Follow all suggested corrective actions and retry system test. If alarm messages remain repeatedly, technical service must be informed. The device can be used only if the system test passes.

•

Preparation One of the following therapies can be selected in the Preparation mode: SCUF CVVH CVVHD CVVHDF TPE Hemoperfusion (Not for USA) Choice of tubing set which will be used (Aqualine for adult and AqualineS for pediatric) has to be performed during Preparation mode. The AQUARIUS system must be prepared for priming. - Refer to section 4.1 for detailed instructions.

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•

Priming A test compares the choice of tubing set (Adult or Pediatric) and tubing set in-situ at the beginning of priming. In the Priming mode the blood and fluid circuit sections are rinsed and filled: At the end of the priming procedure the user can select Reprime or Next to proceed. - Refer to section 4.2 for detailed instructions.

•

Clamp & Pressure Test During this test phase the clamp function, the access pressure function, the return pressure function and the pre filter pressure function are tested. This test is only possible if the air detector has determined that the extracorporeal circuit is free from air. An air free circuit is indicated by a steady green light in the clamp key .

After a successful test the system goes to Start Connection mode. The operator may select from the following options: Go to programming, Go to recirculation, go to Single connection or go to Double connection - Refer to section 4.4 for detailed instructions.

•

Recirculation During Recirculation mode the extracorporeal circuit is flushed until the operator is ready to connect the patient to the AQUARIUS. This mode is started and stopped manually by the operator. The patient parameters may be entered during recirculation by selecting the Go to programming option. If the patient parameters are not entered during Recirculation mode they MUST be entered before starting the treatment. Patient parameters must be entered according to the prescription of the responsible physician. To leave Recirculation mode select Go to connection key to connect the patient to the Aquarius or End treatment remove tube system key to proceed the switch off of the device. - Refer to section 4.5 for detailed instructions.

•

Connecting the Patient NB: Parameters must be programmed before going to connection mode. During the Single connection mode the operator is asked to connect the access segment of the AQUARIUS tubing set to the access limb (red) of the patient’s catheter. After selecting the Start blood pump key the access and return segments of the AQUARIUS tubing sets are filled with blood, up to the air detector. The blood pump automatically stops when the air detector detects blood. During the Double connection mode the operator is asked to connect the access segment and the return segment of the AQUARIUS tubing set to the access limb (red) and the return limb (blue) respectively of the patient’s catheter in the same time. After selecting the Start blood pump key the access and return segments of the AQUARIUS tubing sets are filled with blood and it’s switched automatically into Treatment mode when blood is detected by the air detector system. Treatment can then commence. - Refer to section 4.7 for detailed instruction.

•

Treatment Only if Single connection has been selected: During the Start treatment mode the operator is asked to connect the return segment of the AQUARIUS tubing set to the return limb (blue) of the patient’s catheter. Start treatment: If the operator has not already programmed the patient parameters, it must be done before starting treatment. Treatment begins after selecting the Start treatment key (blood pump must run to start treatment). The patient parameters are displayed on the screen and may be modified during treatment. The operator may stop the filtrate / substitution solution circulation to exchange empty or full bags.

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When Therapy target achieved by time or Therapy target achieved by fluid loss are displayed on the screen, the time target or the fluid loss target respectively have been achieved. The operator may now reprogram to continue treatment or may move into Disconnection phase. - Refer to section 4.8 for detailed instructions

•

Disconnecting the Patient During the Disconnection mode the operator is asked to disconnect patient’s blood access and to connect it to a saline solution bag. The system re-infuses the blood contained in the system to the patient. The blood pump stops when the air detector detects saline solution. By selecting the Next key the operator moves to the Treatment end mode. Reinfusion value onscreen is volume of blood returned to the patient during disconnection. - Refer to section 4.9 for detailed instructions.

•

Terminating the Treatment During the Treatment end mode the operator is requested to remove all tubing from the machine. The operator has to select Aquarius Off key to switch off the Aquarius. - Refer to section 4.10 for detailed instructions

3.7.

Operating Concept Trained and qualified personnel may only operate the AQUARIUS system! During Preparation mode a zoom graphic key allows a step by step guide to the complete installation of the device with visual assistance. Instructions displayed on the screen provide the operating staff with information about subsequent treatment steps. Help function will provide further information on screen at all stages Alarms and messages are colour coded and displayed in separate windows on the screen. Alarms, messages and the end of the respective mode are also indicated to the operating staff by an audible signal. is a rotary switch, located below the display screen. It is used to select and confirm The Main selector button different functions and to modify treatment parameters.

1. Operation status display

2. Mute key

3. Clamp key

6. Blood pump key

4. Main selector button Page 21 of 93

5. Balance Start/Stop key

The individual function keys and their displayed functions are explained below.

1. Operation status display Three status lights indicate the different operation modes. a) An illuminated red status light indicates: Warning ! Alarm or system error b)

An illuminated green and yellow flashing status light indicates Caution] Heater selftest is running. Priming mode is not accessible.

c)

An illuminated green and yellow status light indicates: Caution ! Treatment time has run down or Treatment was stopped Caution ! Bag change required Caution ! Anticoagulant syringe is empty Caution ! AQUARIUS is in Preparation or Recirculation or Connection mode

d)

An illuminated green status light indicates: Treatment is running. No alarms are active

e)

All three status lights illuminating one after the other indicate: Machine is performing system test

2. Mute function key Pressing the Mute key enables the operator to silence the alarm signal for a period of 2 minutes. The LED integrated into the key flashes. If the cause of the alarm cannot be removed within the given period, the audible alarm is reactivated. If another alarm occurs during this period, the audible alarm is generated at once.

3. Clamp function key Pressing the Clamp key opens the return line clamp during air alarm to allow removal of air bubbles from within the tubing set. The LED integrated into the key flashes. When the air is removed, treatment may be resumed by pressing the Blood pump key. The return line clamp is automatically reactivated after 1 minute.

4. Main Selector button The main selector button is a multi-function rotary button. These functions include: a) Selecting function windows by turning the selector button b) Confirming selected functions by pressing the selector button c) Selecting input parameters by turning the selector button d) Opening the input window for the selected parameter by pressing the selector button e) Raising the parameter input for the selected parameter by turning the selector button to the right f) Lowering the parameter input for the selected parameter by turning the selector button to the left g) Confirming the entered parameter by pressing the selector button. The modified parameter is displayed on the screen.

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5. Balance Start/Stop function key Pressing the Balance Start/Stop key stops the filtrate and substitution pumps. This can be used to temporarily stop treatment, for example, to exchange bags. If an alarm occurs in the filtrate and/or the substitution circuits, the pumps stop and the LED integrated into the key starts flashing. After correcting the cause of the alarm the pumps may be restarted by pressing the Balance Start/Stop key. Balance Start/Stop key is also called Start treatment key.

6. Blood pump function key Pressing the Blood pump key starts or stops the flow of blood through the blood circuit. If an alarm occurs in the blood circuit, all pumps stop and the LED integrated in the blood pump key starts flashing. After correcting the cause of the alarm the system is restarted by pressing the Blood pump key again. Filtrate pump, pre-dilution and post-dilution pump start with delay in relation to the blood pump. The Blood pump key is also used to immediately stop all pumps in case of an unpredictable occurrence.

3.8.

Safety Concept The AQUARIUS system safety concept is based on three independent processors. A control system, a protective system, and a display system. The following diagram shows the basic principle.

Display system Parameter and Message Display

Comparison Control system

Protective system

Regulation, Control and Monitoring

Monitoring

Comparison

The control system regulates, controls, and monitors the AQUARIUS system operation. If an out-of-range condition occurs, either a system error or an alarm is generated and the AQUARIUS is switched to the safety mode.

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The AQUARIUS system safety mode is determined by the nature of the occurring alarms: Alarm type

AQUARIUS safety mode

Alarms in blood circuit

• • • • • • • • •

Alarms in filtrate / dialysate circuit

System error

Stops all pumps Closes return line clamp Generates visual and audible alarms Stops filtrate pump Stops pre-dilution pump and post-dilution pump Generates visual and audible alarms Stops all pumps Closes return line clamp Generates visual and audible alarms

The protective system monitors all control system processes. If the protective system detects an alarm or a system error, this alarm or system error will be generated independently of the control system and the AQUARIUS system is switched to the safety mode. The display system is responsible for communication between protective system, control system, and operator. The information coming from protective system and control system are displayed on the screen and the operator’s input is communicated to both protective and control systems.

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4.

Performing a Treatment with AQUARIUS This chapter details how treatments should be performed.

4.1.

Preparing AQUARIUS

Switch ON Plug power plug into the socket and turn socket on. Ensure switch on the power input module is set to the 1 position. This is located on the left side of the AQUARIUS cabinet. Before proceeding, ensure no tubing set or bags are installed on the Aquarius. Press On/Off key located on the right side of the display screen.

3

The system turns on and performs a system test, which checks the main system functions as well as safety control functions. During this process, the three status lights of the operation status display, located above the screen, illuminate one after the other until the system test is finished. The screen displays System test running. The operator must wait until the system test is completed.

4

When the system test is finished, an audible alarm is generated and the green and yellow status lights are illuminated. The pumps stop in the correct position for the tubing set to be installed. The operator can now proceed to select a therapy.

5

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If the system test fails it is important to read the onscreen Help to understand what has failed and follow the suggested corrective action. Select & confirm the Help function and further select & confirm the Error Help function.

6

Selecting a therapy

Select the desired therapy by turning the Selector button until the chosen therapy is highlighted. Confirm the selected therapy by pressing the Selector button . The system switches to the Preparation Mode. If a different therapy is desired select and confirm the Previous function to return to the previous screen. NOTE: When displayed, the Previous function simply takes the operator back one screen. 5

The Hemoperfusion therapy has NOT been cleared for Aquarius instruments sold in the U.S.A. The Hemoperfusion selection will be disabled for Aquarius sold in the U.S.A.

7

Help function will provide further information onscreen.

8

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Preparation Mode - Selecting the tubing set

Select the tubing set by turning the Selector button until the chosen tubing set is highlighted. Aqualine for adult treatment. AqualineS for paediatric treatment

9


10

A Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. Select & confirm Yes to confirm tubing set selection OR Select & confirm No to return to previous step (Tubing set selection screen).

11

Zoom graphic key will provide step-by-step visual helps with graphics. At this stage, zoom graphic function describe Aquarius part functions only.

12

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Preparation Mode - Installing the tubing set & empty bags

13 Warning!

Warning! Warning!

NEVER use any type of fluid or gel on the tubing or the air detector sensor. Any foreign substance applied to the air detector sensor could result in patient injury or death. Use only bloodlines that have been approved by Edwards Lifesciences for use with this instrument. To prevent fingers from getting pinched in the pump chamber, keep fingers out of the pump chamber while rotating the pump heads[LRS 220].

The pump rotors are placed in the Load position at the completion of System Test (rotors horizontal) to properly position the guides for loading the tubing. Always ensure the rotors are in the Load position before starting to wrap the pump segment into the pump. Step 1.

Open both pump doors.

Step 2.

Install the blood pump segment by pressing the tubing, located near the red marker, into the bottom of the blood pump housing and carefully wrapping the segment around the pump by turning the rotor clockwise, guiding the tubing into the pump, then press the tubing into the holder at the pump outlet. Warning!

The operator must make sure that the tubing set is not pinched between the rotor and the housing or twisted in the pump chamber while loading the segment. Aquarius Treatment duration may range to 72 hours. If the tubing is not installed in the pump chamber correctly, the pump segment may leak or rupture during treatment. If the tubing is pinched or twisted during installation of the pump segments, discard the tubing and do not use it for treatment. Use only bloodlines that have been approved by Edwards Lifesciences for use with this instrument.

The blood pump inlet and outlet tube holders are shown below on the left. The picture on the right shows a properly inserted tubing segment that is seated all the way into the chamber.

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Step 3.

Install the filtrate pump segment by pressing the tubing, located near the yellow marker, into the bottom of the filtrate pump housing and carefully wrapping the segment around the pump by turning the rotor clockwise, guiding the tubing into the pump, then press the tubing into the holder at the pump outlet.

Step 4.

Install the postdilution pump segment (top segment with green marker) by pressing the tubing into the inlet (bottom) of the postdilution pump housing and carefully wrapping the segment around the pump by turning the rotor counter-clockwise, guiding the tubing into the pump, then pressing the tubing into the holder at the pump outlet (top).

Step 5.

Install the predilution pump segment (lower segment with green marker) by pressing the tubing into the inlet (bottom) of the predilution pump housing and carefully wrapping the segment around the pump by turning the rotor counter-clockwise, guiding the tubing into the pump, then pressing the tubing into the holder at the pump outlet (top). Close both pump doors.

If the pump doors do not close easily, open the doors and re-check the pump segment for proper positioning. The doors should close easily when the tubing is properly inserted. Warning!

Step 6.

The operator must make sure that the pressure domes integrated in the tubing sets are fixed properly and form-fitting to the pressure sensors on the Aquarius system.

Attach the prefilter pressure dome to the prefilter pressure sensor.

The tubing from the top of the blood pump should project outward and form a loop to prevent kinking of the tubing. Step 7.

Attach the filtrate pressure dome to the filtrate pressure sensor and close the dome clamp.

Step 8.

Attach the return pressure dome to the return pressure sensor.

Step 9.

Attach the access pressure dome to the access pressure sensor and close the dome clamp.

Step 10.

Place the blood leak detector chamber in the holder on the left side of the cabinet.

Step 11.

Insert the tubing coil into the heater, close the door.

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Step 12.

Place the substitution degassing chamber in the holder on the right.

Step 13.

Install the return line in the air detector tube holder by pressing the unit together and push back to hold the return line in place. Ensure return tubing is located securely within the groove of the air detector unit before attempting to press together and push back

Step 14.

Install the return line in the return line clamp.

Step 15.

Connect empty prime collection bag to access line and hang on I.V. pole Warning!

Step 16.

The operator must make sure that the tubing in the pump segments are not dislodged or twisted by installation of the filter. Any time the tubing has been manipulated, visually verify that the pump segment is properly inserted into the pump chamber. [LRS 230]

Select and Confirm next to see the following screen.


14

Zoom graphic key will provide step-by-step visual helps with graphics.

15

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Preparation Mode - Installing the filter and bags & connecting lines

16 For hemoperfusion treatments, the filtrate tubing line must be connected to the Access port to prime the filtrate line as shown in paragraph 4.11 Figure 16. The Hemoperfusion selection will be disabled for Aquarius instruments sold in the U.S.A. Step 1.

Connect the filter to the tubing connections (based on the filter type and therapy selected as described in paragraph 4.11 Aquarius Treatment Choices).

Step 2.

Place the filter in the holder located on the front of the Aquarius System control unit.

Warning! Step 3.

The I.V. pole may only carry a maximum weight of 2.5 kg.

Connect a normal saline solution bag to the return (blue) line and hang it on the I.V. pole or the handle hook. Aquarius was designed to use 5 liter bags. For proper operation of the empty bag detection when using 2.5 liter substitution/dialysate solution bags, program the number of 2.5 liter bags that you will hang and use the number of 5 liter filtrate bags that are programmed (double the capacity of the substitution/dialysate solution). Caution:

Warning!

Warning!

To prevent overfilling or rupturing of the filtrate bags, the bags capacity on the filtrate scale must always be greater than or equal to the Number of Bags entered on the programming screen, multiplied by 5 liters. If 3 is entered for Number of Bags, you must have a 15 liter capacity on the filtrate scale.

Do not hang anything except soft plastic fluid bags on the balancing scale hooks located at the base of the Aquarius System . Foreign objects on the scale hooks can significantly alter fluid balance, resulting in patient injury or death. When using a manifold tubing set with multiple bags, all bag pathways must be unclamped and free flowing, to keep the fluid load centered on the scales. If a substitution bag is kinked or remains clamped, air may be pumped into the substitution lines and balance alarms may occur due to the unbalanced load hanging on the scale. If a filtrate substitution bag is kinked or remains clamped, a filtrate bag may burst and balance alarms may occur due to the unbalanced load hanging on the scale.

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Step 4.

Connect the empty, 5-liter collection bag(s) to the filtrate tubing and hang the collection bags on the filtrate scale. Be sure to open all tube clamps on the bags and manifold set.

Step 5.

Connect the substitution solution bag(s) to the heater tubing and hang on the substitution scale. Be sure to open all tube clamps on the bags and manifold set.

Step 6.

Verify the output of the dialysate/predilution pump (lower green pump) is connected to the bottom of the filter for CVVHD and CVVHDF therapies. The output of the predilution pump (lower green pump) should be connected to the Predilution luer connector, of the prefilter blood line leading to the the top of the hemofilter, for all other therapies.

Step 7.

Verify that all tubing clamps are open for the access, return, filtrate and substitution/dialysate tubing lines. If the substitution line is connected to the predilution luer connector, open the predilution line clamp.

Step 8.

Select and confirm next to prepare the anticoagulant syringe.


17

Zoom graphic key will provide step-by-step visual helps with graphics.

18

Preparation Mode - Preparing the anticoagulant Warning! Only use the anticoagulant syringe type that the Aquarius System has been calibrated to use (for example a BD 50 cc syringe). The Aquarius System must be calibrated for the particular type of syringe you are using by a certified technician. The syringe size is shown at the right of the Prepare syringe screen. Use only Luer-lock syringes and ensure that the anticoagulant line is not clamped prior to the start of anticoagulant infusion.. Use of non-Luer lock syringes or failing to unclamp the anticoagulant line can result in patient blood loss due to coagulation .

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Important: The anticoagulant pump is designed for heparin only.

If anticoagulant is to be infused select & confirm Prepare Syringe OR If no anticoagulant is to be infused select & confirm No Anticoagulant

19 If Prepare syringe has been selected Fill syringe with the anticoagulant concentration & volume prescribed by the physician. Confirm Select volume in Syringe by pressing the Selector button Adjust anticoagulant volume by turning the Selector button left or right as required. Confirm volume input by pressing the Selector button . The syringe driver moves to the correct position. Connect anticoagulant syringe to anticoagulant line. Place anticoagulant syringe in anticoagulant pump. NOTE: Ensure the syringe body & plunger flanges are engaged correctly into pump.

20

Select Prime anticoagulant line by turning the Selector button . as many times as Press Selector button necessary until all air is removed from the line.

21

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Select Program anticoagulant by turning the Selector . button Adjust anticoagulant flow rate by turning the Selector left or right as required. button Confirm flow rate input by pressing the Selector button . Select & confirm Go to Priming to proceed.

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23

If No Anticoagulant has been selected To enter Priming mode select & confirm Start priming. Alternatively the operator has the choice to return to preparing an anticoagulant. To do this they must select & confirm Prepare anticoagulant.

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25

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When Start priming is selected whereas Heater test still running (yellow light flashing) a message “Wait, Heater self-test still running” appears on the screen and Priming screen is not accessible. Message automatically disappears when heater self-test is achieved.

26

4.2.

Priming mode - Priming the AQUARIUS Priming mode - Priming the AQUARIUS Before beginning priming ensure that: All line clamps are open A bag with at least 1 litre of saline is connected to the return (blue) line The supplied waste bag is connected to the access (red) line Ensure that the substitution tubing connector is connected to a bag of substitution/dialysate solution on the substitution scale.

If the TPE or Hemoperfusion therapy is selected, normal saline priming solution may be used in place of substitution/dialysate solution. The Hemoperfusion selection will be disabled for Aquarius instruments sold in the U.S.A. -

Ensure that all access, return, replacement, and filtration tubing clamps are open. Ensure that the substitution degassing chamber and venous drip chamber clamps are closed.

The priming procedure requires 800 ml of saline. The pre- and post-dilution lines are primed with fluid from the substitution/dialysate bag(s). The extracorporeal circuit and the filtrate lines are primed with fluid from the saline bag.

Select Start Priming by turning the Selector button To begin the priming procedure, press the Selector button .

27

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.

At this stage the screen displays Access, Return, and TMP pressures. In the left part of the screen, the components of the circuit that are currently being primed are highlighted. The displayed clock indicates the remaining priming time.

28

Help function will provide further information onscreen

29

The automated priming procedure takes approximately 9 minutes if the blood pump speed remains at the default setting of 80 ml/min for the first 6 minutes, thereafter increasing to 150 ml/min. During this mode, the operator can adjust the blood pump flow rate to reduce priming time. The blood pump flow rate field is highlighted. Press the to modify the flow rate. Enter new flow rate by turning the Selector button to left or right and Selector button to confirm. The new input for the flow rate is displayed on the screen, the pump press the Selector button speed will alter and the clock will recalculate remaining time. Any air remaining in the degassing chamber can be removed by EITHER inversion of the chamber during priming OR aspiration of air via syringe.

At the end of the priming procedure, the Priming completed message is displayed on the screen and an audible signal is generated.

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Help function will provide further information onscreen

31

Priming mode - Wrong tubing set selected or clamp closed message

32

33

If the message Wrong tubing set selected or clamp closed or Wrong tubing set selected appears within the first 2 minutes of priming this could be due to a) one clamp is closed on the substitution line/the substitution bag(s) are not opened, or b) the selected line (Aqualine for adult or AqualineS for pediatric) is not the one which has been installed on the Aquarius by the operator. Ensure that no clamp is closed on the substitution line, and that substitution bag(s) are well opened and positioned correctly on the substitution scale (outlet below) • If selected tubing set and used tubing set correspond, select Yes to confirm the selected line by turning the selector button and pressing it. • If selected tubing set and used tubing set are differents, select No to change selection by turning the selector button and pressing it.

Priming mode - Reprime mode

The operator can now select the Reprime function or the Clamp and pressure test function

34 Page 37 of 93

.If the priming procedure needs to be repeated select & confirm Reprime. The screen will now display Reprime mode.

35 Reprime allows you to select an individual or multiple lines/circuit to be reprimed. All selectable lines/circuit are displayed on the right side of the screen. Select the line(s) requiring reprime and confirm to Start. On the left side of the screen, the circuit or the tubing set currently being primed is highlighted. Reprime may be stopped manually by selecting & confirming Reprime completed, but will stop automatically after the following volumes are pumped: Blood circuit + filtrate pump: Postdilution pump: Predilution/Dialysate pump:

800 ml 160 ml 20 ml for SCUF, CVVH, TPE, HPF 500 ml for CVVHD, CVVHDF

NOTE: If a complete system reprime is required, a minimum of 1 litre of saline must be attached before the Reprime procedure is started. To return to Priming completed mode, select & confirm Reprime completed.


36

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4.3.

Automatic degassing unit priming and use GENERAL DESCRIPTION OF ADU

The Aquarius automatic degassing unit sets the level in the degassing chamber automatically (± 1cm around the light beam). Gas inside the substitution chamber, caused by degassing from substitution/dialysate fluid, is removed by a small pump inside the ADU box (placed inside the Aquarius). Two hydrophobic filters prevent the Aquarius degassing unit contaminating the substitution fluid. One hydrophobic filter is located outside, on the degassing tubing. A second filter is located inside the Aquarius before the pressure unit. The level is controlled by an infra-red light beam and pressure. The Aquarius automatic degassing unit is a microprocessorcontrolled system. The degassing unit works independently from the Aquarius, except for the power supply. Therefore, the system works independently from the software version in use.

AQUALINE INSTALLATION:

Vertical position

Step1: Place ADU fixation clip into its vertical position to allow degassing chamber coming into its housing holder.

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Switch OFF

Step2: Place degassing chamber inside the ADU holder and make sure that holder switch is pressed ON by the chamber.

Switch ON

Horizontal position

Step3: Place the fixation clip to its horizontal position in order to fix the degassing chamber into its functional position. Warning: In case the fixation clip is not well closed, alarm Degassing chamber missing appears at the end of priming.

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From Heater Small line with clamp Inserted into fixation clip housing When complete degassing chamber installation process is achieved, degassing chamber should have position described here right.

To ADU pressure sensor

To green pumps

Step 4: Connect the luer-lock hydrophobic filter from ADU pressure line to the ADU pressure sensor connection.

DO NOT FORGET TO CONNECT DEGASSING LINE TO PRESSURE SENSOR

ADU SELFTEST WARNING ! After starting of the Aquarius device, the user has to verify that the LED inside the reset key lightens yellow with an audible signal. The LED then flashes with a green light which indicates that the self test has passed.

PRIMING

The Aquarius automatic degassing unit starts working during priming mode. When the ADU pressure sensor detects less than -30 mmHg (Post-dilution pump is running) the ADU will automatically prime the degassing chamber (green diode switches from flashing to constant), AFTER 10 seconds FOR 10 seconds.

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If the infra red sensor does not detect water after the initial prime, the pump will start again AFTER 2 minutes. For the second prime, the motor stops priming when liquid is detected at the infra-red sensor (second priming can not run more than 25 seconds). If degassing line (with hydrophobic filter) is not connected to the pressure sensor, ADU status stays OFF (Stand-by mode, green diode flashing). At the end of the priming mode the user has to check visually the fluid level inside the degassing chamber!

FUNCTIONAL MODE

During functional mode, in case light beams don’t detect fluids, the ADU will pump during maximum of 3.5 seconds. If fluid is detected it will pump during additional 2 seconds with maximum of 3.5 seconds for pumping. If fluid is not detected after 3.5 seconds of pumping, pump will start again after 10 seconds. Waiting time during 2 consecutives pumping is always a minimum of 10 seconds. If fluid is detected, pump will not start. ALARMS AND CONTROLS

Four different operation modes are indicated by the LEDs. 1. 2. 3. 4.

ADU Self test: ADU Self test failed: ADU Ready: ADU Working mode:

ADU Red and Green LEDs are on. ADU Red Led is flashing. Additional audible alarm. ADU Green LED is flashing. ADU Green LED is permanently lit.

The Aquarius degassing unit generates audible and visible alarms (ADU Red LED lit permanently) under the following conditions: 1. 2. 3. 4.

If the motor works for more than 25 sec. without detecting a filled chamber. If the hydrophobic filter is blocked (measured pressure less than –300 mmHg). If the system detects a positive pressure higher than +30 mmHg. If self test fails.

In case of an alarm, eliminate the alarm cause. If the Aquarius degassing unit detects “normal conditions” (no blocked hydrophobic filter and a set level) the alarm is disabled. If the alarm is still active, the reset button has to be pressed. The Aquarius Degassing unit resets automatically after 24 hours. If the hydrophobic filter is disconnected from pressure sensor (Pressure>-30 mmHg) or if there is a leakage on the line, the pressure changes to 0 mmHg and the ADU changes to stand-by mode (green flashing diode) During treatment the ADU system will keep the fluid level constant inside the degassing chamber (± 1cm around the light beam) . In case the fixation clip is not with its horizontal functional position, Insert degassing chamber or Degassing chamber missing alarm occurs at the end of priming and during treatment mode.

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4.4.

Clamp and pressure test

If the priming procedure is satisfactory select and confirm Next. The operator will be presented with a Confirm window. At this stage it is IMPORTANT to follow the onscreen instructions. NOTE: Before proceeding ensure Return & Access lines have been connected to the same saline bag. Select & confirm Yes to move to the Clamp & Pressure test OR confirm No to return to previous step.

37

The Clamp & Pressure test must be performed before the Aquarius will proceed to the Start Connection mode. This test is only possible if the air detector has determined that the extracorporeal circuit is free from air. An air free circuit is indicated by a steady green light in the clamp key.

38


39

After the Clamp & Pressure test has completed successfully the operator can select between Go to programming, Go to recirculation or Single connection or Double connection. These functions are listed in the lower right side of the screen and may be selected and activated using the Selector button .

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41

4.5.

Recirculation mode - Recirculating saline solution Recirculation can be entered immediately after priming has completed OR during a treatment when there is a need to disconnect the patient temporarily (e.g. CAT scan). To start recirculation select & confirm Go to recirculation from end of priming OR Recirculation from the Options screen during a therapy.

42

43

A Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. Select & confirm Yes to move into Recirculation mode OR confirm No to return to previous step.

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Press the Blood pump function key to begin recirculation. While the system is recirculating saline solution, the patient parameters may be entered. During recirculation only the Bloodpump circuit is active. i.e. the balance system will not operate. The operator can select between Go to connection, Go to programming , More Or End treatment Remove tube. These functions are listed in the lower right side of the screen and may be selected and activated using the Selector button . 45

When End treatment Remove tube is selected, a Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. Select & confirm Yes to move into End treatment mode OR confirm No to return to previous step

46


47

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4.6.

Programming - Entering Patient Parameters The programming function can be activated at any point after priming is completed or in Recirculation mode or during a therapy. Programming allows the operator to alter program parameters. To commence programming select & confirm Go to programming.

The active parameter available for input is highlighted. When confirmed by pressing the Selector button , the highlighted function has a short definition in the right part of the screen.

48

to open the input Press the Selector button window. The current set value is displayed on the right. A small input window with the word New appears inside the parameter selected. By turning the Selector button to the left or to the right, the new set value can be adjusted. Confirm and store the input value by pressing the Selector button . The new value is displayed and the next parameter is highlighted. 49

Press the Selector button to open the input window and enter the desired value as described above. On the right side of the screen a short description of the current parameter is displayed as described above.

104

105

Selecting and confirming the Reset totals function will zero the following parameters after a confirm window: Fluid loss total, Substitution fluid total, treatment clocks, pre & post dilution and blood volumes pumped since last reset or commencement of therapy. These parameters are found in the Treatment and More screens.

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When all parameters have been entered and confirmed, Select Previous to return to the Start connection screen, Recirculation mode or Treatment screen (depending on where programming had been selected).

4.7.

Start Connection - Connecting the Patient Warning!

Be sure the patient blood access and connections are secured properly. Careful monitoring of the patient for any evidence of extracorporeal blood loss is required to prevent serious injury or death.

Warning!

Air entering the extracorporeal blood circuit can cause fatal air embolism.

Warning!

If the air detected alarm cannot be cleared, discontinue treatment and do not return the extracorporeal blood to the patient.

Warning!

Be sure the patient blood access and connections are secured properly. As defined by the Association for the Advancement of Medical Instrumentation (AAMI), the return Pressure Monitor provides for the detection of bloodline separations. The return Pressure Monitor will trigger an alarm when the pressure decrease is greater than the limit. However, if the needle or cannula becomes dislodged from the return access and remains attached to the bloodline tubing, at typical blood access pressures and usual blood flow rates, the decrease in pressure from the dislodgment will not be sufficient to trigger an alarm condition. This is due to the resistance in the return needle or cannula which will maintain pressures above the recommended set limits of -75, +25 mmHg. Pressure monitoring technology should not be relied upon as the sole method for detecting a breach in the system. The healthcare professional attending the patient must be vigilant in securing the blood access needle or cannula. Careful monitoring of the patient for any evidence of extracorporeal blood loss is required to prevent serious injury or death.

•

Warning!

Connecting or disconnecting the patient to or from the Aquarius system requires aseptic technique and continuous monitoring of all connections to prevent air from entering the system (air infusion) or blood from escaping from the system (blood loss). All system connections must be checked at regular intervals. All blood and fluid paths are sterile and non-pyrogenic.

Warning!

Before connecting the patient and at regular intervals, ensure that the blood lines are not kinked. Kinked blood tubing may cause hemolysis (patient injury).

Single connection

Select & confirm Single connection

50

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Select & confirm A Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. Select & confirm Yes.

51

The message Connection mode is now displayed. If proceeding with the patient connection then follow the onscreen prompts

52 Help function will provide further information onscreen. Clamp saline bag and access line Disconnect access line from saline solution bag and connect to the access limb (red) of the catheter. Open access line and catheter access clamps. Select & confirm Start blood pump function or press Blood pump key.

53

Select & confirm Start blood pump or press . Blood pump key. The extracorporeal circuit is now being filled with blood. The blood pump stops and an audible signal is generated when the air detector detects blood.

54

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Select & confirm Next function. The message Start treatment is now displayed.

55

Help function will provide further information onscreen. Clamp saline bag and return line Disconnect return line from saline solution bag and connect to the return limb (blue) of the catheter. Open return line and catheter return clamps. At this point the operator has the choice of Start treatment or Go to Programming.

56

Attention: The patient parameters must be entered before starting treatment!

•

Double connection

Select & confirm Double connection.

57

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Select & confirm A Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. Select & confirm Yes.

58

The message Connection mode is now displayed. If proceeding with the patient connection then follow the onscreen prompts

59 Help function will provide further information onscreen. Clamp saline bag, access line and return line Disconnect access line from saline solution bag and connect to the access limb (red) of the catheter. Disconnect return line from saline solution bag and connect to the return limb (blue) of the catheter. Open access line and catheter access clamps. Open return line and catheter return clamps. Select & confirm Start blood pump or press Blood pump key function.

60

Select & confirm Start blood pump press Blood pump key function.T The extracorporeal circuit is now being filled with blood. When the air detector detects blood the system automatically switches to the Treatment mode. Select & confirm Next to access to Treatment mode before if necessary.

61

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4.8.

Treatment mode - Description of functions throughout Treatment Attention: The patient parameters must be entered before starting treatment!

When Single connection has been selected, selecting and confirming Start treatment function begins treatment and Treatment mode is displayed. When Single connection has been selected: Blood pump and Balance start/stop button LED’s are now flashing and must be pressed to begin treatment. When pressed, the pumps will start.

62


63

When Blood pump

key has to be pressed before

Start treatment

key.

Start treatment key should be pressed only when the Blood flow rate has reached the prescribed/desired value. If not High filtration ratio message can appear.

64

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Error Help function into Help screen will provide further information regarding this High filtration ratio message.

65

When Double connection is operating, the system automatically switches to the Treatment mode. When Double connection has been selected: Balance start/stop

button LED’s are now flashing and must

be pressed to begin treatment. When pressed, the pumps will start. Start treatment key should be pressed only when the Blood flow rate has reached the prescribed/desired value. If not High filtration ratio message can appear. Treatment screen displays the main patient parameters. The timer shows the remaining treatment time and Next Bag(s) Change in screen shows the remaining time before bag change. All safety controls and functions are active. Pressing the Balance Start/Stop key suspends treatment. This may performed during treatment, such as changing a bag on the scales or anytime it is necessary for the operator to temporarily suspend treatment. When the Aquarius detects a full or empty bag it produces a bag change alert. This automatically stops the predilution pump, the postdilution pump and the filtrate pump. The blood pump continues to run. Treatment is resumed by pressing the Balance Start/Stop

key after bags have been changed.

During treatment the operator has three main choices: Go to programming – enables changes to program parameters More – provides additional information to that available on the main treatment screen. Options – This activates another screen with 5 further information and function screens

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OPTION

Selecting and confirming Options opens the options screen. The user can choose from the following options: HISTORY

The history of the last three (3) treatments is available in this menu. The data is visible as a list or as graphs. Pressures, programmed parameters, patient data, events (errors) are stored. Treatment 1 is the current treatment with Treatment 2 as the previous treatment and so on.

66

History screens can also be accessed from the Help screen whatever mode running.

67

Example: Current treatment, Pressures monitoring list

68

Example: Current treatment, Pressures monitoring graph.

69

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RECIRCULATION

This option starts the temporary disconnection of the patient. The screen menu guides the operator through the disconnection procedure.

70

Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions.

When YES is confirmed, the treatment is temporarily interrupted. All data is stored and disconnection mode for recirculation will open.

71 Disconnect access line from patient catheter and connect access line to a saline solution bag. Press Start Blood pump key to start rinsing the blood from the circuit.

72


73 Page 54 of 93

When clear fluid is detected in the air detection system, Next screen (Return disconnection) will open automatically. Reinfusion (ml) value is the volume of blood returned to the patient during disconnection mode.

After return line is disconnected from the patient, connect it to the same saline solution bag where the access line is connected.

74


75

This Recirculation mode can be accessed before connecting the patient, just after clamp and pressure test. In this case there is no disconnection phase before accessing Recirculation mode. After choosing Go to connection, and following the onscreen instructions, the patient can be connected again and the treatment can continue.

76

When Go to connection is selected and confirmed, a Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. When YES is confirmed, Connection mode opens.

77

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END TREATMENT

This option immediately terminates the treatment. Choosing Yes in the confirmation screen ends treatment and guides the operator to Disconnection mode.

78

Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. When YES is confirmed, all pumps will stop and the disconnection mode window opens as described in Recirculation. .No return to treatment is possible.

79

CHANGE SYRINGE

This option enables the operator to change the syringe or to stop anticoagulation. If initially No anticoagulant was chosen anticoagulation can be started with this option.

80

A Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. NOTE: Before proceeding, ensure anticoagulant line is clamped. Select & confirm Yes to move to a second Confirm window

81

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Confirm window where the operator is again reminded to clamp the anticoagulant line then remove the syringe before confirming Yes. Confirming No simply returns the operator to previous step.

82

A complete process of syringe preparation is required at this step like described chapter 4.1: Prepare anticoagulant. At this stage it is IMPORTANT to follow the onscreen instructions.

83

In case of missing one step of syringe preparation, a confirm window appears depending on the step missing. At this stage it is IMPORTANT to follow the onscreen instructions.

84 THERAPY CHANGE

This option enables the operator to switch between SCUF, CVVH, CVVHD and CVVHDF

85

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Select and confirm new therapy expected

86

A Confirm window appears when the operator attempts any modality change.

87

The screen will guide the operator to properly reconnect the predilution/dialysate line and the filtrate line to fit the new treatment modality Select and confirm YES to validate therapy change and new line positioning achieved.

88

The programmed parameters must be reviewed to ensure they meet requirements of the new therapy. All totals start at 0 when the new treatment mode is started. If the new programmed parameters are not completed , a message is generated depending on the programming parameter missing. Pressing the Balance Start/Stop treatment mode.

key starts new

89

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MORE SCREEN

Additional information can be obtained by Selecting and confirming the More screen

90 o o

Filtrate pressure The actual pressure is displayed. Pre filter pressure The actual pressure is displayed.

o

Temperature in degrees Celsius. This is obtained from the sensors against the degassing chamber.

o

Predilution/dialysate volume This shows the amount of fluid that was delivered by the predilution/dialysate pump by speedometer control. This is the value the pump estimates it has delivered, and may differ from the total in the treatment screen that shows the actual value detected by the scales. The scales regulate the pumps to cover any deviation caused by the differences in line sets. It is normal to see intermittent stoppage of the fluid pumps, as the scales regulate the fluid deviations.

o

Postdilution volume This shows the amount of fluid that was delivered by the postdilution pump by speedometer control. This is the value the pump estimates it has delivered, and may differ from the total in the treatment screen that shows the actual value detected by the scales. The scales regulate the pumps to cover any deviation caused by the differences in line sets. It is normal to see intermittent stoppage of the fluid pumps, as the scales regulate the fluid deviations.

o

Blood volume This shows the amount of blood pumped by the blood pump estimated by speedometer control. This is the value the pump estimates it has moved.

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91

o

Bag change in (h:min) The time remaining until the next bag change is displayed. This is calculated by the mass sensed on the scales.

o

UF Variation The variation of the actual patient fluid loss versus the programmed target is displayed. A variation > 50 ml will cause a balance alarm.

o

Filtration fraction % Filtration fraction % is the ratio of total filtrated volume, divided by the total volume of fluid entering the filter. The calculation is effected by the rates programmed on the predilution/dialysate pump

o

Filtration Ratio % Filtration Ratio is calculated as a percentage of fluid loss (ml/min) divided by blood flow rates (ml/min). In postdilution, it is generally kept below 25%. The filtration Ratio is displayed to give an indication of hematocrit increases in the filter before the postdilution solution replaces the filtrate removed. If the filtration Ratio is too high it may lead to clotting in the filter. The calculation is not effected by the rates programmed on the predilution/dialysate pump.

o

Elapsed time The elapsed time of the programmed treatment is displayed.

o

Access, Return and TMP pressure monitoring are display.

o

BLD% : Over 100% Blood leak alarm is activated

o

To the bottom of the screen a description of all control buttons: i.e.Mute key, Clamp key, Main selector, Balance Start/Stop, Blood pump key.

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THERAPY TARGET ACHIEVED

The treatment will proceed until it achieves a programmed target. This may be time or Fluid loss. At this point the Therapy target achieved by time or Therapy target achieved by fluid loss is displayed and an audible alert is generated.

92

93


94

Throughout the Therapy target achieved phase the Blood pump continues to move blood through the extracorporeal circuit at the programmed rate. The operator can select Go to programming to reset a new target. Refer to section 3.3.1 OR can select Next (Disconnection ) to move into the Access Disconnection mode.

93

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4.9.

Access Disconnection and Return Disconnection - Disconnecting the Patient

When the operator selects & confirms YES, a Confirm window appears. At this stage it is IMPORTANT to follow the onscreen instructions. When YES is confirmed, all pumps will stop and the disconnection mode window opens as described in Recirculation. .No return to treatment is possible. 96

Access Disconnection is now displayed on the screen. Follow onscreen instructions. Clamp catheter access limb and access line (red) Disconnect access line from access limb (red) of the patient blood access and connect it to a saline solution bag. Unclamp access line and saline bag. Press Blood pump key to commence blood flow back to patient. The blood in the extracorporeal circuit is reinfused to the patient. When the air detector detects saline solution instead of blood, the blood pump stops. An audible signal is generated.

97

When operators are satisfied with reinfusion they should select & confirm the Next function.


98

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When clear fluid is detected in the air detection system, the Next screen (Return disconnection) opens automatically. Return Disconnection is now displayed on the screen. Pressing the Blood pump key will start the blood pump, but only for 10 second intervals to return the blood between the air detector and the catheter return line. Reinfusion (ml) value is the volume of blood returned to the patient during disconnection mode.

Clamp catheter return limb and return line (blue) Disconnect return line from return limb (blue) Connect return line to Luer lock fitting on degassing chamber OR to the saline solution bag, if disconnection is prior to Recirculation.

99


100 Select & confirm the Next function. Treatment end will now be displayed onscreen or Recirculation. Before removing Aqualine or disconnecting dome after ending treatment, make sure that pressure level inside tubes are below 400 mmHg. End treatment screen displays all four pressures from the system. Use a 50 ml syringe or Aquasafe to decrease pressure level before removing dome from pressure sensor. When domes are removed from pressure sensors in over pressure conditions, there is high risk of burst and leakage of dome membranes.

101


102

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4.10.

Treatment end - End of Treatment

103

Never switch off the Aquarius device before complete Aqualine tubing set is removed. Before removing Aqualine tubing set from Aquarius system or disconnecting Aqualine pressure domes from Aquarius pressure sensor, ensure and control that pressure levels inside the tubing are below 400 mmHg. If disconnection from the patient has been precipitated by a high pre-filter pressure alarm , do not disconnect the Aqualine pre-filter pressure dome from the Aquarius pre-filter pressure sensor, without first decreasing the pressure inside the pre-filter tubing area. Not respecting these 3 previous warnings can increase the risk of pre-filter pressure dome membrane burst with subsequent user contamination by biological fluids remaining inside the Aqualine tubing set.

Instructions to decrease pre-filter pressure level ¾

STEP1: Prepare a empty 50 ml syringe

¾

STEP2: Use gloves and goggles as per ward protocol

¾

STEP3: Go to Treatment end screen and do not select and validate AQUARIUS OFF key before removing the complete Aqualine tubing set from the Aquarius

103

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¾

STEP4 : Clamp Aqualine pre-dilution access port (red clamp) (A)

¾

STEP5: Disconnect return pressure dome and filtrate pressure dome from return pressure sensor and filtrate pressure sensor respectively (B and C)

¾

STEP 6: Disconnect Predilution line from Predilution access port if necessary and connect empty 50 ml syringe or Aquasafe to pre-dilution access port. (D)

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¾

STEP 7: Open pre-dilution access port clamp by taking care of the syringe plunger in case of over pressure within the tubing. (E)

¾

STEP 8: Fill syringe with fluid until TMP value displayed on screen is below 100 mmHg. (F)

¾

STEP 9: Clamp Aqualine pre-dilution access port and proceed with complete removal of Aqualine tubing set from Aquarius device. Pre-filter pressure dome can now be removed safely from Pre-filter pressure sensor. Remove entire tubing set from system including heating coil, filtrate and substitution solution bags. Remove syringe from anticoagulant pump if used. Ensure nothing remains on the device.

¾

STEP 10: When Aqualine is completely removed from Aquarius system, “AQUARIUS OFF” key can be confirmed by pressing the main selector button to switch off Aquarius device.

F

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4.11.

AQUARIUS Therapies Choices This chapter points out the differences in performing the distinct therapies. For each therapy a diagram illustrates how the tubing runs on the system. The main differences between the treatments are listed below: All pumps are NOT always operated. a) Depending on the treatment, the patient parameters to be entered are different. b) The displayed patient parameters are different. c) During CVVH predilution the free line of the predilution pump is connected to the prefilter d) access line, before the filter. Warning!

All pump segments must be loaded in the pump chambers and primed prior to treatment. The anticoagulant tubing must be primed with normal saline. When priming Aquarius for SCUF, TPE, and Hemoperfusion, the substitution line should be connected to a 1iter bag of normal saline. The Hemoperfusion therapy has NOT been cleared for Aquarius instruments sold in the U.S.A. The Hemoperfusion selection will be disabled for Aquarius instruments sold in the U.S.A. When running SCUF or when not using the replacement solution heater, ensure that the patient’s temperature is maintained. Cold solutions and operation in very cold environments can cause hypothermia.

A dots draw tubing line in the diagram indicates that these pumps are not operating during the respective treatment.

In the following diagrams: Red is used to show the unfiltered blood path;

Blue shows the blood path after the filter;

Yellow shows the filtrate path;

Green shows the substitution solution and dialysate path.

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•

SCUF (Slow continuous ultrafiltration) This diagram illustrates how the tubing runs on the AQUARIUS system during SCUF and indicates pumps that are actives.

the

SCUF

During slow continuous ultrafiltration the predilution pump and the postdilution pump are inactive. The blood is pumped through a highly-permeable filter, and reinfused to the patient. The filtrate is collected in an empty bag hanging on the filtrate scale.

Figure 10 The following patient parameters are entered for a SCUF treatment: Parameter

Blood Pump Rate Time Fluid loss rate Total fluid loss Number of Bags Anticoagulant Anticoagulant bolus

Range

Units

Adult

Pediatric

[30, 450] [0, 99:59] [0, 2000] [0, 32,000] [1, 4] [0, 15] [0, 2.5]

[10, 200] [0, 1000] [0, 15000]

ml/min hh:min ml/h ml 5 liter Bag ml/h ml

The following patient parameters are displayed during SCUF: a) Access pressure b) Return pressure c) TMP d) PD e) Blood flow Anticoagulant Total ml f) g) Total fluid loss

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Increment Adult

Pediatric

10 ml/min 10 minutes 10 / 100 ml/hr 100 ml 1 Bag 0.1 ml/hr 0.5 ml

2 ml/min

•

CVVH (Continuous veno-venous hemofiltration) The next two diagrams illustrate how the tubing runs on the AQUARIUS system during predilution and postdilution and show which pumps are active during CVVH. During this treatment, the output of the predilution pump MUST be connected to the prefilter luer connection before the filter. Warning!

All substitution solutions used must be labeled for intravenous injection, of composition and prescribed by a physician [LRS 213]. Use of incorrect or outdated solutions can result in a patient hazard.

appropriate

CVVH Predilution

Note: During this treatment the free line of the predilution pump is connected to the prefilter access line connection before the filter. During predilution CVVH, the postdilution pump is not active.

Figure 11

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CVVH Postdilution

During postdilution CVVH, the predilution pump is not active. Blood is pumped through a highly-permeable filter and reinfused to the patient. During predilution, the substitution solution is administered immediately before the filter and during postdilution the substitution solution is administered after the filter at the return drip chamber. The filtrate is collected in an empty bag hanging on the filtrate scale.

Figure 12 The following patient parameters are entered for a CVVH treatment: Parameter Range Units Adult

Pediatric

Blood Pump Rate

[30, 450]

[10, 200]

Time Fluid loss rate Total fluid loss Predilution rate Postdilution rate Number of Bags Anticoagulant Anticoagulant bolus Temperature

[0, 99:59] [-100, 2000] [-1000, 32,000] [0, 10,000] [0, 10,000] [1, 4] [0, 15] [0, 2.5] [0 (off), 35, 39]

[0, 1000] [0, 15000] [0, 6000] [0, 4000]

Adult

Pediatric

ml/min

10 ml/min

2 ml/min

hh:min ml/h ml ml/h ml/h 5 liter Bags ml/h ml Degrees C

10 minutes 10 / 100 ml/hr 100 ml 100 ml/hr 100 ml/hr 1 Bag 0.1 ml/hr 0.5 ml

The following patient parameters are displayed during CVVH: a) Access pressure Return pressure b) TMP c) PD d) Blood flow e) Anticoagulant Total ml f) Fluid Loss Total g) Substitution h)

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Increment

0.5 ° C

10 ml/h

•

CVVHD (Continuous veno-venous hemodialysis) This diagram illustrates how the tubing runs on the AQUARIUS system, and shows, which pumps, operated during CVVHD. CVVHD

are

During continuous veno-venous hemodialysis the postdilution pump is not active. Blood is pumped through a semi-permeable dialyser and reinfused to the patient. The filtrate is collected in an empty bag hanging on the filtrate scale. The predilution pump delivers the dialysate to the dialyser, countercurrent to the blood flow.

Figure 13 The following patient parameters are entered for a CVVHD treatment: Parameter Range Units Increment Adult

Pediatric

Blood Pump Rate

[30, 450]

[10, 200]

Time Fluid loss rate Total fluid loss Dialysate rate Number of Bags Anticoagulant Anticoagulant bolus Temperature

[0, 99:59] [-100, 2000] [-1000, 32,000] [0, 10,000] [1, 4] [0, 15] [0, 2.5] [0 (off), 35, 39]

[0, 1000] [0, 15000] [0, 10000]

Adult

Pediatric

ml/min

10 ml/min

2 ml/min

hh:min ml/h ml ml/h 5 liter Bags ml/h ml Degrees C

10 minutes 10 / 100 ml/hr 100 ml 100 ml/hr 1 Bag 0.1 ml/hr 0.5 ml

The following patient parameters are displayed during CVVHD: a) Access pressure b) Return pressure c) TMP d) PD e) Blood flow f) Anticoagulant Total ml g) Fluid Loss Total h) Dialysate

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0.5 ° C

•

CVVHDF (Continuous veno-venous hemodiafiltration) This diagram shows how the tubing runs on the AQUARIUS system and which pumps are operated during CVVHDF.

CVVHDF

Substitution solution and dialysate solution are administered during CVVHDF. All pumps are in operation. Blood is pumped through a highly permeable filter and reinfused to the patient. The postdilution pump is used to administer the substitution fluid and the predilution pump transports the dialysate to the dialyser. The filtrate is collected in an empty bag hanging on the filtrate scale.

Figure 14 The following patient parameters are entered for CVVHDF: Parameter Range Units Adult

Pediatric

Blood Pump Rate

[30, 450]

[10, 200]

Time Fluid loss rate Total fluid loss Dialysate rate Substitution rate Number of Bags Anticoagulant Anticoagulant bolus Temperature

[0, 99:59] [-100, 2000] [-1000, 32,000] [0, 10,000] [0, 10,000] [1, 4] [0, 15] [0, 2.5] [0 (off), 35, 39]

[0, 1000] [0, 15000] [0, 6000] [0, 4000]

Adult

Pediatric

ml/min

10 ml/min

2 ml/min

hh:min ml/h ml ml/h ml/h 5 liter Bags ml/h ml Degrees C

10 minutes 10 / 100 ml/hr 100 ml 100 ml/hr 100 ml/hr 1 Bag 0.1 ml/hr 0.5 ml

The following patient parameters are displayed during CVVHDF: f) Blood flow a) Access pressure b) Return pressure g) Anticoagulant total c) TMP h) Fluid loss total Dialysate d) PD i) Substitution e) TMP j)

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Increment

0.5 ° C

•

TPE (Therapeutic plasma exchange) This diagram shows how the tubing runs and which pumps are operated during TPE.

TPE

During TPE blood is pumped through a plasma filter. The corpuscular blood components are reinfused to the patient. FFP (Fresh Frozen Plasma) or albumin solution is delivered to the patient via the postdilution pump. The plasma is collected in an empty bag hanging on the filtrate scale. The predilution pump is not operational during this treatment

Figure 15 The following patient parameters are entered for a TPE treatment: Parameter

Range Adult

Pediatric

Blood Pump Rate

[30, 450]

[10, 200]

Time Plasma flow rate Total Plasma volume Number of Bags Anticoagulant Anticoagulant bolus Temperature

[0, 99:30] [0, 3000] [0, 10000] [1, 4] [0, 15] [0, 2.5] [0 (off), 35, 39]

[0, 1200]

Units

Increment

ml/min

Adult 10 ml/min

h:min ml/hr ml 5 liter Bags ml/h ml Degrees C

30 minutes 10 ml/hr 10 ml 1 Bag 0.1 ml/hr 0.5 ml 0.5 ° C

The following patient parameters are displayed during a TPE treatment: a) Access pressure Return pressure b) TMP c) PD d) Blood flow e) Anticoagulant total ml f) Total Plasma g)

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Pediatric 2 ml/min

•

Hemoperfusion This diagram shows how the tubing runs and which pumps are operated during hemoperfusion.

Hemoperfusion

During hemoperfusion blood is pumped through a hemoperfusion cartridge. Certain substances (e. g. toxins) are adsorbed and the cleansed blood is reinfused to the patient. Only the blood pump is in operation.

The Hemoperfusion therapy has NOT been cleared for Aquarius instruments sold in the U.S.A. The Hemoperfusion selection will be disabled for Aquarius sold in the U.S.A.

Figure 16 The following patient parameters are entered for a hemoperfusion treatment: Parameter

Range

Units

Adult

Pediatric

Blood Pump Rate

[30, 450]

[10, 200]

Time Blood volume Anticoagulant Anticoagulant bolus

[0, 99:59] [0, 5000] [0, 15] [0, 2.5]

Increment Adult

Pediatric

ml/min

10 ml/min

2 ml/min

h:min L ml/h ml

10 minutes 10 ml 0.1 ml/hr 0.5 ml

The following patient parameters are displayed during a hemoperfusion treatment: a) Access pressure b) Return pressure c) TMP d) Blood flow e) Anticoagulant Total ml f) Total blood volume g) PD

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5.

AQUARIUS Alarms and Messages

5.1.

Description of Alarm Operation Alarm signals are visual and audible. The red status light located in the operation status display illuminates. The cause of the alarm is displayed in a yellow or red window on the screen. The audible signal can be muted for 2 minutes by pressing the Mute key while the alarm remains active. If the alarm condition is not corrected after 2 minutes, the audible alarm is reactivated. If another alarm occurs within the 2 minutes of mute, an audible alarm signal is generated. Messages are displayed in a yellow window; e.g., a bag exchange message. Aquarius system response to a blood circuit alarm:

Audible and visual alarm

All pumps stop. (Status Indicator in the Return line clamp closes.

Blood pump and

Balance Start/Stop

keys flash.)

The return line clamp only closes, if air or microfoam are detected or the return pressure drops below the lower alarm limit.

Resetting the alarm:

Correct the cause of the alarm. Press the

Press the

Blood pump key to resume treatment.

Balance Start/Stop key to resume treatment.

Aquarius system response on filtrate/substitution circuit alarms:

Audible and visual alarm Filtrate pump stops Predilution pump and postdilution pump stop

Status Indicator in the

Balance Start/Stop key flashes

Resetting the alarm:

A balance alarm occurs when a 50 ml (20 ml for pediatric) difference is detected between the fluid volume pumped and the scale measurement of the substitution or filtrate solutions. This volume may result in an additional 50 ml (20 ml) infusion to the patient or 50 ml (20 ml) of fluid removed from the patient if a tubing line is kinked or blocked. Warning!

If repeated balance alarms occur, stop treatment and notify technical support to protect patient from excessive fluid removal or infusion. If the issue cannot be immediately resolved, end the treatment and remove Aquarius from use until the device is properly calibrated by an Edwards Lifesciences-Certified technician.

Correct the cause of the alarm. Press

Balance Start/Stop key to resume treatment.

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5.2.

Alarms, Messages, System Errors, and Removal Options •

Alarms

Red indication If the AQUARIUS system detects an out-of-range condition during the system test or during operation or if parameters exceed or drop below the respective limits, an alarm message is generated and the AQUARIUS system switches to the safety mode. If the following system errors are not corrected after system test and if during treatment no correction is possible, please call technical service to repair the AQUARIUS. CPU1: error1 CPU CPU1: error2 CPU CPU1: error3 CPU CPU1: XRAM CPU1: CODE CPU1: EEPROM CPU2: error1 CPU CPU2: error2 CPU CPU2: error3 CPU CPU2: XRAM CPU2: CODE CPU2: EEPROM

Master CPU Register test failed Master CPU RAM test failed Master CPU jump test failed Master CPU extern RAM failed Master CPU program code test failed Master CPU calibration data test failed Controller CPU Register test failed Controller CPU RAM test failed Controller CPU jump test failed Controller CPU external RAM test failed Controller CPU program code test failed Controller CPU calibration data test failed

CPU1: program run CPU2: program run

Program failure Master CPU Program failure Controller CPU

CPU1: ADC/Voltage CPU2 CPU1: Voltage sensors CPU1: ADC/Voltage CPU2

Voltage supply or AD-converter failure Voltage supply or AD-converter failure Voltage supply or AD-converter failure

Display: High access pressure Low access pressure Air Detected

Cause:

Access pressure has exceeded the upper alarm limit. Access pressure has dropped below the lower alarm limit. Return tubing line contains air or microfoam.

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Options for error removal: √ √ √ √ √

Check access blood line, including access and prefilter sensors, for kinks or occlusions. Check position of patient access. Check blood flow rate.

Make sure that tubing line does not contain air. Check access and filter connections for sources of air leaks. √ When you clear the Air Detected alarm, make sure there is no air or foam trapped in the line between the return deaerator chamber and the patient end. √ To remove air from the tubing line: √ Step1. Open the return line clamp. Step 2. Remove all air from the tubing set. Step 3. Close the return line clamp. Step 4. Resume treatment by starting the blood pump. Warning! If the air detected alarm does not clear and air is visible in the venous deaerator chamber, disconnect the patient from the instrument and recirculate per your centre’s procedure. √ Note: You may see microbubbles smaller than the air detector sensitivity.

Display:

Cause:

Options for error removal:

Balance system off

The balance system has been off √ for 5 minutes.

Balance Alarm

Balancing deviates from the set values entered by the operator.

Check substitution line

√ √

Or √

Balance alarm Check filtration line

Switch on Check flow rates of the pumps. Check fluid removal and turnover input parameters. Note: Potentially pumps can't deliver program with very high volume because of pressure peaks. Check bag hanging on scale. (Filtration or substitution) Check tubing set for narrow sections. (Filtration or substitution) Check filter for blood leak and exchange filter if required. Check pressure conditions. Check blood flow rate. Check blood pump tube. Check tubing set for narrow sections.

Blood leak

Filtrate / plasma contains blood.

√ √ √

Blood flow failure

The number of revolutions of the pump exceeds or falls below the alarm limits by ± 5%.

√ √ √ √

Blood pump off

The blood pump was manually switched off for 1 minute.

Check transducer connections

The pressure domes have not √ detected any pressure change for 15s.

Clamp heparin line

The anticoagulant syringe has been removed

√

Clamp anticoagulant line

High filtrate pressure

Filtrate pressure exceeds or falls below the alarm limits.

√ √ √ √

The number of revolutions of the pump exceeded or fell below the alarm limits by ± 5%.

√ √ √

Check pressure sensor. Check tubing set for narrow sections. Check filter and exchange if required. Check blood flow-to-fluid removal or blood flow-to turnover ratio. Check blood flow rate. Check blood pump tube. Check tubing set for narrow sections.

A key press longer than 60 s. detected by master-cpu.

√

The keyboard needs repair

Master key transfer

A key press longer than 60 s. detected by master-cpu.

√ √

The keyboard needs repair The communication cable is defective

Main battery high

At the main battery high voltage is √ detected √ √ No bag was hung on the scale √

Low filtrate pressure Filtrate flow failure

Keyboard failure

No bag Indication battery high

Postdilution failure

√

At the power fail indication battery √ high voltage is detected √ √ The number of revolutions of the √ pump exceeded or fell below √ alarm limits by ± 5%. √

Press blood pump again.

key to switch blood pump on

Ensure the domes are properly connected.

Control charging voltage/unit Control/change battery Control AD-converter/CPU Hang empty collection bag and/or substitution solution bag on the scale Change battery Control charging voltage Control AD-converter/CPU Check blood flow rate. Check blood pump tube. Check tubing set for narrow sections.

Predilution failure

The number of revolutions of the pump exceeded or fell below alarm limits by ± 5%.

√ √ √

Check blood flow rate. Check blood pump tube. Check tubing set for narrow sections.

High prefilter pressure

The prefilter pressure exceeds upper alarm limit.

√ √ √

Check pressure sensor. Check filter and exchange if required. Check blood flow.

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Display:

Cause:

Options for error removal: √

Check tubing set for narrow sections.

Return pressure exceeds or falls below the alarm limits.

√ √ √ √

Check return line for connection, kinks or occlusions. Check return pressure transducer. Check blood flow rate. Check position of patient access.

Degassing chamber missing

The substitution degassing chamber is not inserted or the sensors are defective.

√

Heparin syringe missing

An anticoagulant rate has been programmed and no syringe has been inserted in the plunger.

√ √

Insert the substitution chamber properly. Ensure the chamber is in contact with the sensor of the holder. If this doesn’t help switch off heater to end the treatment. Then call technical service. Insert anticoagulant syringe if anticoagulant is needed Set anticoagulant rate to zero ( No anticoagulant required)

Low Prefilter pressure High return pressure Low return pressure

The anticoagulant syringe is not inserted properly High Temperature

Temperature controller high (Fluid pumps will not run)

A high temperature is detected in √ the substitution degassing √ chamber √

Check the substitution line for kinks Open heater door to cool the heater down. If the alarm disappears the pump will start automatically

The substitution solution temperature is above 40,5 °C The plate temperature of the heater is above 53°C

Low temperature low

The substitution fluid temperature √ has been below 33°C for more √ than 10 minutes.

High TMP

TMP exceeds or drops below respective alarm limits.

√ √ √

Check pressure sensor. Check tubing set for narrow line sections. Check blood flow-to-fluid removal or blood flow-toturnover ratio.

Too many bags are on the scale.

√

Ensure that the same number of substitution solution and filtrate bags hang on the scale hooks. Note: The maximum number of bags on the scale is 4 substitution solution and 4 filtrate bags.

Low TMP Too much weight

•

Check the heater bag Check substitution temperature

Messages

Yellow indication If the AQUARIUS system detects out-of-range conditions or reminders that do not conform to the intended use of the system, the operator gets detailed information defined for the individual conditions and the system switches to the safety mode. Display: Air detected, Clamp/Pressure test disabled

Cause:

The air detector detected air in the return line.

Options for error removal: √ √ √

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Ensure the return tubing does not contain air. Ensure the return tubing is installed properly in the air detector sensor’s clamping mechanism and is not scratched or damaged. After correcting the error, Select and confirm Previous, then perform the clamp/pressure test again to proceed.

Display:

Anticoagulant off

Cause:

The anticoagulant rate is programmed to zero.


√ √ √

Warning! If the air detected alarm cannot be cleared, discontinue treatment and do not return the extracorporeal blood to the patient. If anticoagulant is not required proceed to next screen. If anticoagulant is required, insert a syringe containing anticoagulant and program the desired anticoagulant rate. Insert an anticoagulant syringe in anticoagulant pump or program the anticoagulant rate to zero.

Heparin syringe missing

The anticoagulant syringe is not in the anticoagulant pump.

Balance initializing…

Scales and fluid pumps initialise √ when the balance system is started. √

Balance system off

The balance system is off, all fluid pumps are stopped.

√

Correct the cause and switch the balance system on again.

Blood detected

During the connection phase blood √ is detected in the return line

The blood pump stops and starts now only for 5s again. Switch to treatment mode

Blood pump off

The blood pump was manually switched off.

Press blood pump on again.

Change substitution bag

The filtrate bag has reached √ maximum permissible weight or the √ substitution solution bags do not contain solution.

Exchange full filtrate bag for empty bag Exchange empty substitution solution bag for new bag filled with solution

After a power failure, the main power supply battery must be charged.

√

Power failure indication (beep) battery is low

√

The battery is automatically charged if you go on with this treatment. This message indicates that in the event of a power failure the Aquarius will run less than 2 min The battery is automatically charged if you go on with this treatment. This message indicates that in the event of a power failure the Aquarius will beep less than 2 min Check the substitution line and the filtration line if the bags are opened, all clamps are removed and the tubes and bag inputs are not kinked.

(Blood pump stops)

Change filtrate bag Main battery low

Indication battery low

√

√

√

This is just a reminder Occurs each time the balance system is turned ON

key to switch blood pump

Check lines

The postdilution pump has been stopped for longer than 3 min to regulate the fluid loss.

√

Check transducer connections

The return dome or prefilter dome are not properly connected.

√

Exchange filter and set

The suggested filter life of 72 hours √ has been exceeded

Exchange filter and tubing set

Heater cools down

If balance system has stopped for a √ prolonged period, the heater plate temperature is above 43°C.

The pumps stop until the temperature is in a safe condition (below 42° C). This may take up to 10 min. The pumps will start automatically.

Heater self test running.

Heater Selftest is in progress when √

Wait until heater Selftest is completed.

! Wait

Insert BLD chamber

the start-priming screen is reach.

•

The blood leak detector has not been inserted into the blood leak chamber.

√ √ √

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During clamp and pressure test no pressure increase is found when the clamp is closed

When heater Selftest is finished, the yellow diode upper the screen become fixed (green diode still fixed during and after heater Selftest) Insert the chamber Reprime to correctly fill up the chamber. Ensure no scratches or marks are present on the Aqualine chamber

Display: Insert tube to air detector

Cause:

The air detection system is not operational after priming

Options for error removal: √ √

High filtration ratio

√ 1. Fluid removal rate exceeds 33% √ of the blood flow rate. √ √ 2. Exchange of fluid or plasma

across the membrane is too high in comparison to the blood flow rate.

Insert correctly return line into the air detection system. Make sure that the air detection system is well inserted, if not push it back firmly. Ensure the green diode of the clamp key is lighted. Decrease fluid removal or plasma exchange rate Increase blood flow rate Evaluate ratio of pre vs. post dilution substitution solutions.

3. The post dilution substitution rate is higher than what is acceptable for the current blood flow rate. Negative UF

A negative UF is programmed

√

This is just a reminder

No fluid chamber detected

The substitution degassing chamber is not inserted.

√

Insert the chamber correctly

Please program

Hourly fluid loss or fluid loss total is √ not programmed

Please wait

The balance system is stopped

√

Program dialysate

In CVVHD dialysate rate is not programmed.

√

Program goal

Treatment goal is not programmed. √

Program treatment pumps

In CVVH/CVVHDF pre- and postdilution/postdilution and dialysate are not programmed.

√

Pump door open

One of the pump doors is open.

√

Close pump door/s.

√

Further information is available from the help screens. During the first minute of treatment this is a reminder.

Read error help instructions Low return pressure

The return pressure is below 10 mmHg

√

Heparin syringe empty.

The syringe located in the anticoagulant pump is empty.

√ √ √ √ √ √

Clamp line.

•

Select programming mode and program hourly fluid loss and fluid loss total.

This is an indication that the system will start automatically after some minutes. Select programming and program a dialysate rate. Select programming and program either time, fluid loss and fluid loss total, or both. Select programming and program pre- and postdilution or postdilution and dialysate rate.

Clamp anticoagulant line. Take syringe out of pump and disconnect from line. Fill new syringe with anticoagulant. Enter syringe volume and confirm. Place syringe in pump and connect line. Confirm

System Errors

Red indication During the system test (after switching the system on) and also during operation the AQUARIUS system automatically performs tests to check the safety-critical components. If errors occur during these tests, the system switches to the safety mode and generates a system error message. This error message appears with the abbreviation CPU1 (control processor unit1) or CPU2.

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both

Display: Access pressure sensor

Cause: • • •


Access pressure values deviate √ from limits. Control system and protective system values deviate from √ each other (outside of limits) During clamp/pressure test no pressure increase is detected Air detector test failed. √

Air detector

•

Blood leak detector

•

Blood leak detector does not √ work properly.

Blood pump

• • • •

Flow rate test failed. Blood pump drive defective. Blood pump is not stopped. Actual value of number of revolutions deviates from set value outside of limits. Actual values of control and protective systems deviate from each other (outside of limits) Actual values deviate from limits The data transfer values regarding the operation mode deviate between master- and controller CPU. Filtrate pressure values deviate from limits. Values between protective system and control system deviate from each other (outside of limits) Flow rate test failed. Filtrate pump drive defective. Filtrate pump is not stopped. Actual value of number of revolutions deviates from set value outside of limits. Flow rate test failed. Postdilution pump drive defective. Postdilution pump is not stopped. Actual value of number of revolutions deviates from set value outside of limits.

√

Flow rate test failed. Predilution pump drive defective. Predilution pump is not stopped. Actual value of number of revolutions deviates from set value outside limits.

CPU1: anticoagulant pump

• •

CPU1: operation mode CPU2: operation mode

•

Filtrate pressure sensor

• •

Filtrate pump

Postdilution pump

• • • • • • •

Predilution pump

• • • •

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√ √

Restart system (no tubing must be installed). If the error cannot be reset, put system out of operation and notify technical support. Access pressure dome may not be connected correctly (ensure by pressing the dome firmly towards the access transducer) Press blood pump key. If error cannot be reset, put system out of operation and notify technical support. Press the Blood pump key. If the system error cannot be reset, put system out of operation and notify technical support. Switch system off and on again after approx. 1 minute (no tubing must be installed). Press blood pump key. If the error cannot be removed, notify technical support.

√

Restart system (no tubing must be installed). If the error cannot be reset, put system out of operation and notify technical support.

√ √

Press blood pump key to start a new check. If the alarm appears again, call technical support.

√

Restart system (no tubing may be installed). If the error cannot be reset, put system out of operation and notify technical support.

√

Switch system off and on again after approx. 1 minute (no tubing must be installed).

√ √

Press Balance Start/Stop key. If error cannot be reset, notify technical support.

√

Switch system off and on again after approx. 1 minute (no tubing may be installed).

√ √

Press Balance Start/Stop key. If the error cannot be reset, put system out of operation and notify technical support.

√

Switch system off and on again after approx. 1 minute (no tubing must be installed).

√ √

Press Balance Start/Stop key. If the error cannot be reset, put system out of operation and notify technical support.

Display: Prefilter pressure sensor

Cause: • •

Processor

•

Protective system

• •


Prefilter pressure values √ deviate from alarm limits. Values between protective system and control system deviate from each other (outside of limits) RAM, EPROM or EEPROM are √ defective. Error during data transfer. Power supply for protective system is defective.

√

√ √

√

Return line clamp

• • •

Clamp test failed. Clamp does not close. Clamp does not open.

Return pressure sensor

•

Return pressure values deviate √ from limits. Values between protective system and control system √ deviate from each other (outside of limits). During clamp/pressure test no pressure increase is detected

•

•

Scale

• •

Screen

•

Values between protective and √ control system deviate from each other (outside of limits). Actual values are outside of limits. Data transfer to display system √ defective. √

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Restart system (no tubing may be installed). If the error cannot be reset, put system out of operation and notify technical support.

Switch system off and on again after approx. 1 minute. If the system error cannot be reset, put system out of operation and notify technical support. Press blood pump key or Balance Start/Stop key. Switch system off and on again after approx. 1 minute. If the error cannot be reset, put system out of operation and notify technical support. Correct tubing set position in clamp. Press blood pump key. If the error cannot be reset, put system out of operation and notify technical support. Restart system (no tubing may be installed). If the error cannot be reset, put system out of operation and notify technical support. Clamp pressure test: o Press domes firmly towards the transducer. Return and pre filter domes must be connected correctly o Insert tube into return line clamp o Ensure that there is no leakage between blood pump and return line clamp Restart system (no tubing may be installed). If the error cannot be reset, put system out of operation and notify technical support.

Set up safety mode for the patient. Switch system off and on again after approx. 1 minute (no tubing must be installed). If the error cannot be reset, put system out of operation and notify technical support.

6.

AQUARIUS Technical Data This chapter contains information about individual components and general technical information about the AQUARIUS system. For more detailed technical information please contact the AQUARIUS manufacturer.

6.1.

Dimensions and Weight Dimensions Height: Width: Depth: Floor space: Weight:

6.2.

170 cm (without I. V. pole) 50 cm 60 cm approx. 55 cm (W) x 65 cm (D)

approx. 75 kg

Electrical Power Supply Voltage

230 V ∼ (Alternating voltage) ± 10%, 50 Hz 115 V ∼, 60 Hz Currents 2.2 A with 230 V 4.4 A with 115 V

6.3.

Electrical Safety (complying with EN 60601-1) Manner of protection against electrical shock The AQUARIUS system is classified in class 1. Degree of protection against electrical shock

Symbol: The AQUARIUS system is classified as type B. Fuses:

Main Fuses: 2 x 3.15 A T, 20 x 5 fine fuse with time delay, glass body Nominal voltage: 250 V AC max. Fuse switch value 3.15 A / 250 V AC

Heater Fuse: 1 x 3.15 A T, 20 x 5 fine fuses with time delay, glass body Nominal voltage: 250 V AC max. Fuse switch value 3.15 A / 250 V AC Battery Fuses: 1 A T, plastic body soldered on secondary power supply Nominal voltage: 250 V AC max. Fuse switch value 1 A / 250 V AC 1 x 3.15 A T, 20 x 5 fine fuses with time delay, glass body Nominal voltage: 250 V AC max. Fuse switch value 3.15 A / 250 V AC Page 83 of 93

After BG-E414-02: 1 x 3.15 A T, plastic body soldered on secondary power supply Nominal voltage: 250 V AC max. Fuse switch value 3.15 A / 250 V AC Storage battery: Maintenance-free lead storage battery, LC-R061R3PG Capacity: 6 V, 1.3 Ah

6.4.

Power Outage Operation If the mains power supply fails during a treatment, the AQUARIUS automatically switches to storage battery power supply, until the emergency mains power supply is available. Storage battery operation is indicated via an audible signal. On the screen the "Power fail" message is displayed. During this period, the fluid circuit (Substitution and filtrate) is stopped. Circulation through the blood circuit is maintained. If the power supply is restored, the fluid circuit may be resumed. If the power supply is not restored before the end of battery operation (after approx. 2 min), AQUARIUS system will be switched off (safety mode) and all pumps will stop. The return line clamp is still open to enable manual return of blood from the extracorporeal circuit. If the AQUARIUS system is stored over a longer period the manufacturer recommends to connect the system to the power outlet and charge the storage battery for 15 hours every half year. Also charge the storage battery for 15 hours before initial set up and installation. The battery has to be changed every 2 years.

6.5.

Technical Data of Individual Components Component

Access pressure sensor

Air detector

Alarm Blood leak detector Blood pump

Display monitor

Specification

Measurement method: Contact measurement Measuring range: -250 to +200 mmHg Measuring accuracy: ± 5mmHg Upper alarm limit: automatic setting between –50 and +100 mmHg Lower alarm limit: automatic setting between -200 and -50 mmHg Alarm window size during treatment: 150 mmHg Method: Ultrasonic air bubble detection at 2.3 MHz Sensitivity: Air bubbles at a volume of 1 µl at a blood flow rate of 200 ml/min Microfoam at a volume of 20 µl at a blood flow rate of 200 ml/min The alarm signal may be muted for a period of 2 minutes. The alarm loudness is 65 dB (A) within a distance of 1 m. Measurement of clouding flow rate Sensitivity: 2 ml of blood in 1000 ml (± 10%) of filtrate at a filtrate pump of 100 ml/h up to 12000 ml/h (at a hematocrit of 32%) Input range adult: 30 ml/min – 450 ml/min Step-by-step: 10 ml/min Input range pediatric 10 ml/min – 200 ml/min Step-by-step: 2 ml/min Flow rate accuracy: Setting ± 5% Pressure range for the specified accuracy: see defined values for access pressure and prefilter pressure 10.4 “ TFT colour monitor

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Component Filtrate and substitution solution scale

Filtrate pressure sensor

Filtrate pump

Specification

Measurement method: via strain gauge Max. load: 0 to 20 kg, max. 4 bags with 5 l of substitution fluid each ± 50 g for adult, ± 20 g for pediatric Accuracy: Ultrafiltration adult: -100 ml/h to +2000 ml/h Ultrafiltration pediatric 0 or 50 ml/h to 1000 ml/h Note: At a fluid removal rate of –100 ml/h, a maximum positive balance of 1 l is permissible for adult treatment. Measurement method: Contact measurement Measuring range: -250 to +400 mmHg Measuring accuracy: ± 10 mmHg Upper alarm limit: +350 mmHg Lower alarm limit: - 200 mmHg Input range adult: 0 or 100 – 12,000 ml/h Input range pediatric 0 or 100 – 11,000 ml/h Flow rate accuracy: Setting ± 10% Pressure range for the specified accuracy: see defined values for filtrate pressure

Fluid loss Adult:

Heating unit

Heparin pump

PD (Pressure Drop) Postdilution pump

Predilution pump

0 or 10 – 2000 ml/h Step-by-step 10 ml/h Maxi for total fluid loss: 32000 ml Fluid loss Pediatric: 0 or 10 – 1000 ml/h Step-by-step 10 ml/h Maxi for total fluid loss: 15000 ml Adjustable substitution temperature 35°C to 39°C, adjustable in 0.5°C increments, or 0 (Off). Accuracy: ± 0.5°C. Alarm is triggered if temperature is > 40°C. Plate working range 21°C to 53°C. Alarm is triggered if temperature is > 57°C. Accuracy: ± 0.3°C Syringe pump for use of 50 ml syringes (Calibration necessary). Input range: 0.5 – 15 ml/h, Steps: 0.1 ml/h Flow rate accuracy: Setting ± 0.5 ml/h Heparin bolus: 0.5 – 2.5 ml/bolus via patient parameter function Max. back pressure value, which does not influence the flow rate accuracy: 650 mmHg Prefilter pressure-return pressure Measuring accuracy: ±10 mmHg Input range adult: 0 or 100 – 10,000 ml/h Step-by-step: 100 ml/h Input range pediatric 0 or 100 – 4,000 ml/h Step-by-step: 10 ml/h Flow rate accuracy: Setting ± 10% Pressure range for specified accuracy: see specified values for return pressure The total flow rate resulting from the flow rates of predilution and postdilution pump must not exceed 9000 ml/h. Input range adult: 0 or 100 – 10,000 ml/h Step-by-step: 100 ml/h Input range pediatric: 0 or 100 – 6,000 ml/h Step-by-step: 10 ml/h Flow rate accuracy: Setting ± 10% Pressure range for specified accuracy: see specified values for return pressure

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Component Dialysate pump

Prefilter pressure sensor

Processors Return line clamp Return pressure sensor

Syringe for use in syringe pump

TMP

ADU Infra-red diodes

Specification

In CVVHD-CVVHDF predilution pump is used as dialysate pump with the following specifications: Input range adult: 0 or 100 – 10,000 ml/h Step-by-step: 100 ml/h Input range pediatric: 0 or 100 – 6,000 ml/h in CVVHDF 0 or 100 – 10,000 ml/h in CVVHD Step-by-step: 10 ml/h Flow rate accuracy: Setting ± 10% Pressure range for specified accuracy: see specified values for return pressure. Measurement method: Contact measurement Measuring range: -150 to +500 mmHg Measuring accuracy: ± 5 mmHg Upper alarm limit: +400 mmHg Lower alarm limit: -100 mmHg 2 x CPU 80517 and 1 x Intel With no power applied, the clamp is open Occlusion of line up to 1200 mmHg Measurement method: Contact measurement Measuring range: -50 to +350 mmHg Measuring accuracy: ± 5 mmHg Upper alarm limit: automatic setting between 110 and 300 mmHg Lower alarm limit: automatic setting between 10 and 200 mmHg Alarm window size during treatment: 100 mmHg List of authorised syringes 1. Fresenius Injektomat Syringe 50ml 2. Original Braun Perfusor Syringe 50ml 3. Becton-Dickinson Plastipak 50ml[60ml]* 4 mechanical equivalent products * Important: Use only with max. 50ml, even if the max. volume of the syringe is 60ml Return pressure + Prefilter pressure - Filtrate pressure 2 Measuring accuracy: ± 10 mmHg Upper alarm limit: automatic setting to +400 mmHg Plasma therapy: at 100 mmHg Lower alarm limit at – 30 mmHg 50 Hz +/- 10%

ADU Pressure working range (alarm range) ADU Power supply

-300 mmHg to + 30 mmHg

ADU Audible Alarm

1 Hz +/- 0.5 Hz

ADU Constant level

± 1cm around the light beam

From Aquarius : + 24 V

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7.

Guidance and manufacturer declaration – Electromagnetic emissions

7.1.

Safety rules – Electromagnetic Compatibility Medical electrical equipment needs special precautions regarding electromagnetic compatibility. In respect of this, the installation and operating notes must be kept in accordance to the guidance and manufacturer declarations. The emission and the immunity characteristic of the device is in accordance to the requirements for not life-supporting devices in a typical clinical environment under consideration of normal use. Especially prudence is required by the use of portable and mobile RF communication equipment as cellular phones, mobiles, laptops with W-LAN / Bluetooth and other similarly equipment. The device should not be used adjacent to or stacked with other equipment. If adjacent or stacked use is necessary, the device should be observed to verify normal operation in this configuration in which it will be used. Not authorized variations, modifications, reparations, services and the use of unregistered equipment may result in increased emissions and/or decreased immunity of the device, therefore this is not permitted.

7.2.

Guidance and Manufacturer declaration – Electromagnetic emissions and immunity

Guidance and manufacturer declaration- Electromagnetic emission The Aquarius is designed for use in the electromagnetic environments specified below. The user of the Aquarius has to ensure, that the device is used in such an environment. Radiation measurement Conformity Electromagnetic area RF-Emission (CISPR 11) Group 1 The Aquarius uses RF-energy only for its internal function. Therefore the RF-emissions are very low. It is unlikely, that electronic systems in the area of the Aquarius are disturbed. The Aquarius is suitable for use in all establishments, RF-Emission (CISPR 11) Class B including domestic establishments and those directly Harmonic current emissions Class A connected to the public low-voltage power supply network (IEC 61000-3-2) that supplies buildings used for domestic purposes. Voltage fluctuation and flicker Confirms (IEC 61000-3-3) Table I

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Guidance and manufacturer declaration- EMC Immunity Guidance and manufacturer declaration- EMC Immunity The Aquarius is designed for use in the electromagnetic environments specified below. The user of the Aquarius has to ensure, that the device is used in such an environment. Immunity test

EMS-Electrical static discharge (IEC 61000-4-2)

EMS-Bursts (IEC 61000-4-4)

IEC 60601-test level

± 6 kV direct-discharge

± 6 kV direct-discharge

± 8 kV air-discharge

± 8 kV air-discharge

± 2 kV power supply input lines and PE

± 2 kV power supply input lines

± 1 kV for input and output lines

n.a.

EMS-Surges (IEC 61000-4-5) ± 1 kV differential mode

EMS-Voltage dips, short interruptions and voltage variations on power supply input lines (IEC 61000-4-11)

Compliance-Level

± 1 kV differential mode

± 2 kV common mode

± 2 kV common mode

< 5% UT

< 5% UT

(> 95% dip in UT for ½ (> 95% dip in UT for ½ cycles) cycles) 40% UT

40% UT

(60% dip in UT for 5 cycles)


70% UT

70% UT



< 5% UT

< 5% UT

Electromagnetic environment – Guidance

Floors should be wood, concrete or ceramic tile. If floors are covered with synthetic material, the relative humidity should be at least 30 % Mains power quality should be that of a typical commercial or hospital environment.

Mains power quality should be that of a typical commercial or hospital environment. Mains power quality should be that of a typical commercial or hospital environment. If the user of the Aquarius requires continued operation during power mains interruptions, it is recommended that the Aquarius be powered from an uninterruptible power supply or a battery.

(> 95% dip in UT for 5 (> 95% dip in UT for 5 seconds) seconds) EMS-Power frequency (50/60 Hz) magnetic field

3 A/m

3 A/m

(IEC 61000-4-8) Note: UT is the a.c. mains voltage prior to application of the test level. Table II

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Power frequency magnetic fields should be at levels characteristic of a typical location in a typical commercial or hospital environment.

Guidance and manufacturer declaration- EMC Immunity Guidance and manufacturer declaration- EMC Immunity The Aquarius is designed for use in the electromagnetic environments specified below. The user of the Aquarius has to ensure, that the device is used in such an environment. Immunity test

IEC 60601-test level

Compliance-Level

Electromagnetic environment – guidance

Portable and mobile RF communications equipment should be used no closer to any part of the Aquarius , including cables, than the recommended separation distance calculated from the equation applicable to the frequency of the transmitter. 3 Vrms 150 kHz to 80 MHz

3 Vrms 150 kHz to 80 MHz

d = 1,167· √P

EMS-Conducted Disturbances (IEC 61000-4-6)

Recommended separation distance:

3 V/m 80 MHz to 2,5 GHz

3 V/m 80 MHz to 2,5 GHz

d = 1,167· √P for 80 MHz to 800 MHz d = 2,33· √P for 800 MHz to 2,5 GHz Where P is the maximum output power rating of the transmitter in Watt (W) according to the transmitter manufacturer specifications and d is the recommended separation distance in meters (m).

EMS-Radiation (IEC 61000-4-3)

Field strengths from fixed RF transmitters, as determined by an electromagnetic site survey,a should be less than the compliance level each frequency rangelb. Interference may occur in the vicinity of equipment marked with the following symbol:.

Note 1: At 80 MHz and 800 MHz the higher frequency range applies. Note 2: The guidelines may not apply in all situations. Electromagnetic propagation is affected by absorbation and reflection from structures, objects and people. a Field strengths from fixed transmitters, such as base stations for radio (cellular/cordless) telephones and land mobile radios, amateur radio, AM and FM radio broadcast and TV broadcast cannot be predicted theoretically with accuracy. To assess the electromagnetic environment due to fixed RF transmitters, a electromagnetic site survey should be considered. If the measured field strength in the location in which the Aquarius is used exceeds the applicable RF compliance level above, additional measures may be necessary, such as reorienting or relocating the Aquarius . b Over the frequency range 150 kHz to 80 MHz, field strength should be less than 3 V/m. Table III

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Recommended separation distances between portable and mobile RF communications and the Aquarius device The Aquarius is designed to operate in an electromagnetic environment, in which radiated RF-disturbances are controlled. The customer or the user of the Aquarius can help prevent electromagnetic interference by maintaining a minimum distance between portable and mobile RF communications equipment (transmitters) and the Aquarius as recommended below, according to the maximum output power of the communications equipment.

Rated maximum output power of the transmitter W 0,01 0,1 1 10

Separation distance according to frequency of transmitter m 80 MHz to 800 MHz 800 MHz to 2,5 GHz 150 kHz to 80 MHz d = 1,167· √P

d = 1,167· √P

d = 2,33· √P

0,1167

0,1167

0,233

0,37

0,37

0,74

1,167

1,167

2,33

5,30

5,30

7,4

11,67 11,67 23,33 100 For transmitters rated at a maximum output power not listed above, the recommended separation distance d in metres (m) can be estimated using the equation applicable to the frequency of the transmitters, where p is the maximum output power rating of the transmitter in watts (W) according to the transmitter manufacturer. NOTE 1: For 80MHz and 800MHZ, the separation distance for the higher frequency range applies. NOTE 2: These guidelines may not be applicable in all situations. Electromagnetic propagation is affected by absorbation and reflection from structures, objects and people. Table IV

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8.

AQUARIUS Cleaning and Disinfection

8.1.

Cleaning The surfaces of the AQUARIUS system, of the cabinet and the wheeled base may be cleaned with a soft, damp cleaning cloth. For surface disinfection use a mild standard surface disinfection agent for medical equipment. Follow the instructions of the manufacturer regarding use, concentration, fields of application, and safety. Do not use disinfection sprays! Do not use any cleaning or disinfection agents for cleaning the display screen!

8.2.

Disinfection The AQUARIUS system components do not come into contact with the patient’s blood. Therefore, disinfection of internal components is not required. Only the tubing sets and the filters have direct blood contact. These items are disposables that are discarded after every treatment.

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9.

AQUARIUS Warranty and Liability The manufacturer can only guarantee the safety, reliability, and performance of the AQUARIUS system, if the operator follows the instructions contained in this manual. Warranty includes the repair and replacement of defective parts, as long as these are defects due to construction, fabrication, and material. The following actions immediately void the warranty: Modifications and repair work of the AQUARIUS system is done by unauthorized persons. If the intended use of the AQUARIUS system is ignored. If the AQUARIUS system is operated improperly. If valid standards regarding electrical installations are not fulfilled. If errors or system malfunction is caused by improper operation or normal wear.

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10.

References

Franz, H.E.: Blutreinigungsverfahren. Technik und Klinik, 4. Aufl. Thieme, Stuttgart-New York 1990 Franz, H.E.: Dialyse für Pflegeberufe, 2. Aufl. Thieme, Stuttgart-New York 1996 Franz, H.E.; Risler,T. (Hrsg.): Klinische Nephrologie: Handbuch für Klinik und Praxis. Ecomed, Landsberg/Lech 1993. Losse; Renner: Klinische Nephrologie in 2 Bänden, Band 1, Thieme, Stuttgart-New York 1982 Mertens; N.E. Lison: Kontinuierliche extrakorporale Blutreinigungsverfahren während der Intensivbehandlung. Ein praktischer Leitfaden. Pabst, Lengerich 1992 Meyer, G.: Hämodialyse – Technik und Anwendung. Pabst, Lengerich 1994 Niles, R.; Reinartz, K.: Die kontinuierliche Hämofiltration auf der Intensivstation. In: Die Schwester/Der Pfleger, Heft 11 (1992) 1050-1054 Rieger, W.: Kontinuierliche Blutreinigungsverfahrne in der Intensivmedizin. Pabst, Lengerich 1994 Roche Lexikon Medizin. 3. Aufl., Urban & Schwarzenberg, München-Wien-Baltimore 1993 Schleipfer, D. (Hrsg.): Dialysetechnik. 4. Aufl., bionic, Friedrichsdorf 1988 Schönweiss, G.: Dialysefibel, 2. Aufl., abakiss, Bad Kissingen 1996 Schulz, W.: Medikamente und Niere. Dustri Deisenhofen 1994 Borger, L.: Dialyse. Urban & Schwarzenberg, München-Wien-Baltimore 1997 Nowack, R.; Birck, R.: Dialyse und Nephrologie für Pflegeberufe. Springer, Berlin-Heidelberg-New York 1999 Larsen, R.: Anästhesie und Intensivmedizin für Schwestern und Pfleger. 4. Aufl., Springer, Berlin-Heidelberg-New York-Tokio 1994 Lanzendörfer, C. et al.: Innere Medizin. Springer, Berlin-Heidelberg-New York-Tokio 1998 Schmidt, R.F.; Thews, G. (Hrsg.): Physiologie des Menschen. 20. Aufl., Springer, Berlin-Heidelberg-New York 1980

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Edwards Lifesciences Services GmbH Edisonstr. 6 85716 Unterschleißheim Germany Edwards Lifesciences LLC One Edwards Way Irvine, CA 92614 USA

03/2006 English, Version 6, Rev. A © Copyright 2005, Edwards Lifesciences LLC All rights reserved.

Aquarius for Platinum Software version 6 - Operator+Manual - English

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