Major air leakage, dark blood out of dialyser, FCN 5.11.001

[Paul Addison]

Hi all,
This fault has occurred on 2 machines (AK200S) so far; several times at the start of dialysis, but also a couple of times approaching 2 hours into treatment. The blood from the dialyser to the bubble trap is noticed to be suddenly very dark, the venous pressure is high (220mmHg) and TMP rises. Then a 'Major air leak' message is displayed, later followed by error 5.11.001.
The machines seem fine in the workshop and I'm running out of ideas! Has anyone experienced anything similar before, or have any ideas as to the cause? We have some theories but nothing concrete yet.
Thanks
Paul

[Ian Wilde]

Hi Paul,

Have you been doing dummy treatments in the workshop or just completing the function check and then monitoring?
Have you changed dialyzers at all?  Is the dialysate compartment being primed fully before the blood side?


Ian

[Paul Addison]

Hi Ian,

I have performed simulated patient treatments but with no issues. It has occurred with fx80 and fx100 dialysers but we are keeping tabs on this. Interesting last question; here, they wait until the 4:00 is displayed before lining and priming and wait until it asks for the Bicart. At other units they line and prime when the priming light flashes. The 2 machines are now back in use as dialysers are currently the primary suspect.

Thanks

Paul

 

From: Ian Wilde [via ART Forum] [[hidden email]]
Sent: 08 July 2015 13:22
To: Addison Paul (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST)
Subject: Re: Major air leakage, dark blood out of dialyser, FCN 5.11.001

 

Hi Paul,

Have you been doing dummy treatments in the workshop or just completing the function check and then monitoring?
Have you changed dialyzers at all?  Is the dialysate compartment being primed fully before the blood side?


Ian

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[Ian Wilde]

Well, yes you certainly can prime once the light is flashing but here we tend to wait until the 4 hours is up on screen too.

[Paul Addison]

It has now occurred on 2 further machines so it seems more likely to be down to something other than particular machines, though it's still a mystery