You shouldn't need to talk with the machine tech. If they make bicarb and acid on site any tech should be able to tell you what the specific gravity is. I wouldn't think that the machine tech is the only one to make bicarb and acid.

Is the machine tech at your clinic also the cheif tech? Can you not DEMAND the MD and unit manager make an appointment to talk with the tech? I know I sure would! I have patients ask to speak with me all the time and if I can't give the anwser they want I will get the anwser for them. Is this guy or gal just that mean tthat they will not talk with you? Affraid you will stump him?

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Originally posted by m micone:
I'm a patient, on a fresenius 2008h. I commisserate, but you may be blaming symptoms on the wrong culprit. Cramping is a fluid removal question. Appetite can relate to many things, but it's most often an adequcy of dialysis question.
I've been having a problem with low co2 due to using renagel. We tried riasing the bicarb proportioning on the machine settings to compensate. The highest we can et is 37, due to the bicarb mix used on all the machines. If you set it higher, you get no result. The only time our machines alarm for high conductivity is when the techs change to a full bicarb jug in mid tx and the machine needs a moment to adjust to the fresh batch. For cramping, if you are taking off more than two litres, ask about sodium modeling scripts. Hope this helps.

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I asked several staff about the bicarb proportioning and specific gravity. They didn't seem to know these two terms at all and did not seem to know who to refer me to. I finally located the person who mixes the bicarb. My unit has a maintenance person doing the job. She gave me the product insert for Naturalyte 4000. It says 1 part acid to 44 parts bicarbonate base and water is used. Nominal dilution is 1:1.72:42.28. Sodium =37mEq/L. Bicarbonate = 37mEq/L. Chemical Composition: 650gm. Sodium B, Bicarbonate. U.S.P. Dissolved 81.25.

Next I will ask this person if she can tell me the specific gravity.

Where is the info found about the proportioning of the machine? What do you mean by proportioning of the machine?

It says on the bicarb insert: "Check conductivity and pH of dialyzing fluid before starting tx and each time solution is added (AAMI RD5)".
Conductivity and pH is checked in my unit with strips prior to the tx, but it is not checked when the jugs run out and new bicarb is added.

Greg, or Jane, or patient, or whoever you are: (remember your IP address is displayed)

Previously, a tech told me bicarb is mixed in a large tub. The instructions for Naturalyte 4000 only mention mixing for 2.1 gallon jugs.

OK I'm sorry I miss understood about the strips.

Now for the bicarb: Is it mixed in the jugs or is it mixed in a bulk tank?Either way here could be one of the problems. If they are mixing it in the jugs they could be adding to little water for it to mix properly. If they are mixing it in a bulk tank ie 50 gallons at a time this could be the problem as well to little water. In my opinion it is really unsafe to mix bulk bicarb using these little boxes. I know we used to use the for our Acute unit. Not to mention that it takes alot of time to open all of those little cartons. I wouldn't want to be the one doing it. It also could be that the person making it is using enough water but is adding to much bicarb.

How long has this problem been going on? Is it just in the winter months? If so it could be that the water used to make the bicarb is too cold and may need to be mixed longer. I know at my clinic this is the case we have to mix a little longer in winter than we do in the spring and summer.

mgunsoius,
I will ask next time I go to dialysis how the bicarb is mixed. It may be that the little boxes are not used when they make the bicarb and it was just that I was given an insert from a box to answer my question about the proportioning.

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Originally posted by Greg:
jtech,
I asked the techs and RNs what the proportioning of the machine is and none of them could answer the question. I also asked about the proportioning of the bicarb and no luck there either. I won't be able to answer these questions until I can talk to the machine tech. I would prefer using factory mixed solutions as I think they're safer, but I doubt that I could request it as it wouldn't be cost effective.

mgunsoius,
Likewise, unable to find out about the hydrometer measurement of specific gravity until I can talk to the machine tech.

Anxiety,
I follow the diet very carefully and have excellant labs each month. I have never skipped or shortened a tx in years of dialysis. I understand about the clocks and I am the one who insists the techs not end the tx until the RTD clock has elapsed. No other patient's machine has high cond. alarms. The problem is with my machine, alone. My RNs and techs can tell you that, because it makes their job a whole lot harder as they always have to stop what they are doing to silence the alarms on my machine.

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Originally posted by m micone:
SMILER I'm at my unit right now. Are your specs for naturalite a definite result. We use the 6000 on 2008H. Where can I find more tech info. m micone

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Well, this time, he took the liberty to lower the cond. range because he felt that the lower cond. was in limits for a 2K and thats what he had to do from his end despite my tx symptoms with lowered cond.

What was causing the cond. to rise over 14.5 (bear with me as hopefully I will explain this correctly and if I don't you will still be able to see what the problem is) was a valve, or a valve behind the check valve was open all the way, instead of being at the quarter position it should of been at. This caused excessive pressure to come into the machine causing the cond. to rise too high setting off the alarms. I think he said this interfered with the machine pulling the concentrate rather than by positive pressure.
So, he shut the valve back to the quarter postion ending the alarm situation.

I don't recall what the technician said about why there were no alarms some days. Could it have something to do with pressure in the loop?

He said the alarms should not have compromised my txs as by running the clock out I got the time back. But I told him several other technicians have said multiple alarms does compromise the tx and my clearances have been up and down ever since the problem started. He had no comment to that.

I told him that I understood why he decided to handle the problem as he had, but now I had a new problem to solve, and after the tx was over I would be letting him know if I am symptomatic from the lowered cond. He gave me a way to get in touch with him in the future.

I asked him if there was a way to increase the cond. rate of the machine with possibly another bicarb solution. He said if the bicarb solution was changed it would raise my potassium. So, he didn't seem to think there is any way this can be done.

I am confused about your comment that all dialysis patients more or less feel unwell on dialysis. I didn't feel unwell the whole time my my machine's cond. was up at 14.3 -14.5. Thats many months of good txs. I don't know how cond. of 14.0 could be good for me if it makes me feel so sick. Nothing about the tx has changed but the cond. unless its an untrue reading.

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Originally posted by Greg:
GTSCSS,
There were no alarms this tx. since the cond. is now at 14.0. The valve the technican spoke of is in the wall where the concentrate comes in. You're saying this valve being open all the way had nothing to do with the problem? He also said that in his regular maintenance he changed out the diaphrm, springs and seals.

I am confused about your comment that all dialysis patients more or less feel unwell on dialysis. I didn't feel unwell the whole time my my machine's cond. was up at 14.3 -14.5. Thats many months of good txs. I don't know how cond. of 14.0 could be good for me if it makes me feel so sick. Nothing about the tx has changed but the cond. unless its an untrue reading.

I will tell the technician what you said. Thanks for the good wishes.

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I also agree about the loop pressure.We have ours regulated down to 4 psi on both the acid and bicarb. Our conductivity on our machines run 13.8 - 14.2.

It may just take some time for your body to adjust to the rapid changes it has gone through the past few months. I would give it a month or so and let everything stablize in your body and then see how you feel.

Also mention to your machine tech to check the acid and bicarb pump volumes and maybe recalibrate the conductivity cells in the machine. It is not a huge task to do this and won't take him but about an hour or so. We do this on every quarterly PM that we do on our machines.

Here's your problem: pressure regulation in the concentrate supply loop is being controlled by partially closing the concentrate valve at the station.

You are on a central feed for the acidified concentrate - machines are designed to draw concentrate via the concentrate pump and are not designed to accept concentrate under pressure. When the concentrate feed pressure exceeds 3 psi or thereabouts you can have a situation where the concentrate is forced passed the spring / check valve assembly on the concentrate pump causing momentary increases in the final conductivity.

The older the pump spring / check, and the higher the pressure the more likely this will occur. This affect can be transitory dependent on how much concentrate is being taken from the feed piping by the other machines. (Pressure in the line decreases as more machines draw concentrate). Or it can be a matter of where your station is relative to the feed piping. (First on the line the higher the pressure).

Since you state this generally happens toward the end of your treatment I would also guess that you dialyze on the last shift of the day or your treatments may run longer than others during that shift. As more machines (or their dialysate flow) are turned off the pressure in the concentrate line increases. The higher the pressure the greater the chance that the concentrate will force through the pump.

So there is nothing wrong with the machine (in fact given the circumstances it's doing exactly what it is supposed to do by alarming) just "not the best design" for the concentrate feed loop.

I don't know where I am on the loop, but my chair is located in the middle of a wing. I do run the last shift. I'm pretty sure my tx time is longer than most of the patients on my wing except for one. Two or three get off before me.

Other than making the high conductivity alarms go off, how else should this situation have affected my txs? Did it, or did it not, compromise the txs?

Update:
With the first tx on my machine, since the high cond. alarm problem was resolved, not being a good one, I was very nervous about going to my next tx. When I got to tx., my regular machine was not there and a different machine was there in its place. The conductivity on this machine was similar to that of my, machine since the technican recalibrated it (13.7-14.0), so I prepared for the worst. To my great surprise, the tx at this lower cond. rate was problem free. What do I deduct from this?

Since you stated somewhere along the line that you dialyze by the clock on the machine (rather than the clock on the wall) I would guess your treatment time is sufficient.

The change in final conductivity should be based on the expected final conductivity of the formualtion used. If this is correct than the machine delivers the correct dialysate and alarms accordingly.

As far as your feeling poorly this can be the result of many things which may or may not have anything to do with your treatment -certainly not the machine if it is functioning correctly. This is something which you need to discuss with your physician - I don't think you'll get the answer here.

As far as comments ie - jiffy lube dialysis -
well that's a perception. No one would deny that there are units out there where quality of care is a phrase and not a reality, however by and large most dialysis units deliver acceptable care - maybe your's is the exception - if so then you should address this with the facility's manager and medical director.

Since this is the "technical" forum we should limit our discussion to technical topics - when we attempt to diagnose specific problems experienced by a patient we run the risk of misinforming. In our attempts to be helpful we may ultimately hinder a resolution.

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Originally posted by mgunsolus:
I agree with you chuck! Whoever Greg is it is starting to get stupid! I think that you greg just needs to talk with your doctor and clinic manager and quit going on and on with this post. I am also through with posting replies with this topic!

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