- Monitor ultra filtrate fluid for obvious blood during procedure. A few fibres may rupture initially but this should subside over a 10 minute period. If it persists and is significant the procedure must be stopped.
- Ensure all alarm checks on AK10 blood pump have been carried out prior to commencement of procedure. Low venous pressure alarm must be set above 0.
- Air trap must have 10ml air space at top. No air or blood clots should be alowed to travel back to the patient.
- Only sterile equipment to be used.
- Medical review of: results of FBC, UEC's, BSL, Ca, Mg, PO4, Coags prior to commencement of procedure.
- Prior to commencement of procedure - have two nurses check all lines according to manufacturer's instructions.
- The blood flow rate should not exceed 200ml/minute, PF1000N - optimal flow rate is 80-130ml/minute.
- The venous haematocrit should be less than 65.

OUTCOMES: - The patient will remain haemodynamically stable throughout the procedure.
- The patient will maintain a core temperature of 36 to 37%C.
- Plasma exchange as directed.
- Replacement fluid volume = extraction fluid volume at completion of procedure.

EQUIPMENT:
- Clean large dressing trolley

(Bloodside) - AK 10 blood pump
- 1 Gambro plasmapheresis kit including PF1000N filter (check filter for damage)
- 2 x 1000ml normal saline with 5000 units Heparin.
- 1 x 500ml normal saline with 5000 units Heparin (for last flush)
- Heparin infusion 5000 units in 50ml = 100 units/ml through syringe driver. The patient should receive 800- 1000 units/hour. As per MO instructions.
- Sterile jug and recirculator
- Atraumatic clamps x 3

(Reinfusion side) - Infusion warmer
- Infusion solutions as ordered (colloid)
- 2 med pumps and 2 giving sets

SETUP: - Remove filter from package and place vertically in appropriate holder (arterial end down).
- Place the blood lines on the machine according to diagram in CVVHD policy. (A)
NB: Ensure sterility of connections is maintained.
- Remove the protection caps from the blood parts on the plasma filter and attach the blood line connectors. Arterial line to bottom and venous line to top.
- Remove the cap with the medical grade paper from the filtrate port, and attach the filtrate line. Clamp the filtrate line close to the plasma filter. (See diagram B).
WARNING: Do not remove the dense screw cap from the second part of the plasma filter.
- Attach the arterial end of the blood line to the 1 litre normal saline flask containing 500 units Heparin.
- Place the free end of the venous line with the recirculation hook attached into the sterile jug.
- Connect Heparin infusion and prime line.

Priming:
- "Air detect bypass" button should be on (ie illuminated).
- Remove any obstructing clamps and start the blood pump. Run at 50-100mls/hour.
- Clamp the venous line next to the filter when the priming solution reaches it. Fluid will then travel out ultra filtrate line, and prime it with approximately 1000mls.
- Unclamp the venous line and rinse and prime the remaining venous blood lines with remaining 1 litre then 500ml bag of normal saline and Heparin.
- Remove any remaining air from the blood circuit. Adjust the fluid level in the venous chamber with a syringe until the level is 10mm below the top of the drip chamber
- Stop the pump, clamp arterial and venous lines and attach sterile recirculator hook on the venous end, to the arterial end. Then unclamp arterial and venous lines (leave filtrate line clamped) and run pump at 50-500 mls/hour to eliminate minute air bubbles. Turn "Air Detect Bypass" button OFF (that is, not illuminated and will detect air in circuit).
- Place ultra filtrate drainage IMED line into IMED pump (for extraction). Place primed fluid replacement IMED line into 2nd IMED pump. (This line is primed with the colloid replacement fluid).
- All connectors must be carefully checked.

The plasma filter is now ready for use.
TREATMENT: WARNING: The arterial membrane pressure of 200mmHg for PF1000N should never be exceeded.

Caution: If filter is primed and there is a time delay prior to commencement (if the fluid is not recirculating), then a fresh 250ml of priming solution should be flushed through the system.

- Connect blood lines to vas cath using a strict aseptic technique as described in CVVHD treatment initiation. REMEMBER to remove the heparin locks.
- Remove all clamps.
- Start the blood pump slowly (50ml/minute) while watching the arterial and venous pressures.
- Commence Heparin infusion as ordered (usually 1000 units loading dose and 1000 units/hour).
- Turn on IMED pumps in and out and set to required exchange rates. Usually 500mls/hour in, and 500mls/hour out. Record input/output.
- If everything is stable increase speed of pump to 100mls/minute.
- Maintain haemodynamic, cardiac and temperature monitoring throughout.

Caution: Never stop the blood pump before the ultra filtrate pump. If it is necessary to recirculate the extracorporeal blood through the plasma filter, both the infusion and ultra filtrate pump must be turned off. This will prevent dilution or haemoconcentration of the circulating blood. Monitor ultra filtrate fluid for obvious blood during procedure. A few fibres may rupture initially, but this should subside over a 10 minute period. If it persists and is significant the procedure must be stopped.


REF: Gambro Product Information