Using LifePort Perfusion

Using LifePort Perfusion
Kidney Transporters
at PHNT
This protocol outlines the management & use of LifePort
Perfusion Transporters in PHNT.
Do not attempt to use the LifePort Transporters unless you
have received formal training.
Contents
1
Preparation of consumables/ perfusates
2
Ice preparation into non sterile ice container (in theatre)
3
Preparing to load the perfusion circuit
4
Loading the cassette and perfusion circuit (non sterile)
5
Energise the Transporter
6
In-situ perfusion of the kidneys
7
Cannulation is the key step to using the transporters
8
Transferring the kidney into the cradle and cassette
9
Loading the Cassette and commencing perfusion
10
Initial perfusion
11
LifePort pump perfusion transporter storage and monitoring
12
Download and data analysis
13
Removing the kidney from the transporter for transplant
14
Cleaning
15
Trouble shooting
Using LifePort Perfusion
Kidney Transporters
The decision to use the LifePort pump perfusion transporter is based on the discussion between
transplant co-ordinator and surgeon. This will include factors of how many theatre staff, patients’
blood group and tissue type if known, availability of equipment, training and skill of retrieval team
in respect of the LifePort transporters. Packing of the kidney remains the responsibility of the
transplant co-ordinator.
1
Preparation of consumables / perfusates
LifePort transporters and consumables are stored in theatre cupboard opposite
theatre co-ordinator 1’s desk.
Please take both transporters and 2x LifePort sterile perfusion circuits to theatre.
Both transporters will be plugged into mains electricity to ensure full capacity of
power from batteries.
Perfusates: frozen stored in “bone freezer” & cool in the bottom of ICU’s blood
fridge. Please see Kardex ( Appendix 1)
Fill chilly bin half full with crushed or cubed ice, then bury perfusion fluids into ice
and transport to theatre.
2
Ice preparation into non sterile ice container (in theatre)
Place approximately 2L of ice from the chilly bin into the ice container, pushing it as
far as possible into the ice bath
Top up with clean water approximately 1-2L in each
Add more ice and water until the icebox is full, maximizing the amount of ice added.
3
Preparing to load the perfusion circuit
Open 2x LifePort consumable packs and place on sterile field. The sterile person
should check security of all connectors and for signs of damage to the equipment
Record the Circuit Lot Number and manufacture date
Remove the kidney cradle from the box and retain on the back bench/table for later
Non-sterile person to decant 1L KPS-1 fluid into the cassette
Record Perfusate Lot Number and expiry date
The sterile person must close both lids and pass cassette to non-sterile person or
load cassette into the ice container and transporter.
4
Loading the cassette and perfusion circuit (non sterile)
Once the cassette is in the ice container. Place the tube frame upright and
perpendicular to allow the hinges to clip in the receivers on the pump deck.
Carefully assemble the tube frame on to the pump deck (see diagrams).
Step One
Step Two
Step Three
Step Four
Step Five
Step Six
5
Energise the Transporter
Step Seven
On the control panel press ‘power on’ wait for a few minutes for the system to
initialise and carry out self-diagnosis. If there are no alarm conditions (if alarm
sounds see ‘trouble shooting’ section at the end of protocol), press ‘wash’ button
to perfuse the wash circuit and allow air to be removed from the line for a few
minutes. Monitor for leaks on the whole circuit especially the connections.
If required, agitate the tube frame and LifePort to dislodge air locks in the tubing/
sensor areas
Press ‘stop’ and ‘prime’ to perfuse the infusion line of the circuit and remove air.
The system should be left in ‘prime’ mode whilst waiting for the kidney to be
attached to the perfusion system
Replace the white cover transporter lid to maintain or lower the displayed
temperature to less than 8oC.
6
In-situ perfusion of the kidneys
As per protocol for surgical technique, 1st bag of 1L perfusate contains Heparin
5000iu (Appendix 2)
Back table perfusion and dissection as per normal.
7
Cannulation is the key step to using the transporters
Select a cannula that matches the size and anatomy of the aortic patch. A 7x20
cannula will normally be satisfactory.
If a kidney has more than one renal artery, ensure that all arteries are cannulated
and adequately perfused. A coupler may need to be used if > 1 artery away from
main aortic patch.
Step Eight
Step Nine
Step Ten
Step Eleven
Step Twelve
8
Transferring the kidney into the cradle and cassette
Place the cannulated kidney into the organ cradle and snap the cannula into the
cannula mount. Cover the kidney with the netting to secure it in place.
Step Thirteen
Step Fourteen
Make sure that the Seal Ring cannula is securely closed and attached to the artery so it will
remain in place during transportation and perfusion.
Visually inspect the renal artery, ensuring there are no twists, kinks or occlusions or
overstretching before getting ready to place the cradle in the cassette.
Ensure the veins are not occluded or trapped by the cassette fittings and is draining
freely into the reservoir.
9
Loading the Cassette and commence perfusion
Non-sterile person should remove the transporter white lid and then the cassette
outer cover and press ‘stop’.
Sterile person to drape the top of the LifePort with sterile drape provided in pack.
Remove the inner sterile lid and place on the back-table.
Transfer the cradle into the cassette. Take care to avoid trapping the infusion line
between the cradle and the cassette.
Step Fifteen
Connect the infusion line to the proximal connector and detach the distal
cap and place on the back-table (do not dispose as you will need it later)
Step Sixteen
Step Seventeen
Press ‘prime’ to remove air bubbles from the infusion circuit into the reservoir via
the distal open end of the Seal Ring cannula. Tap/flick the cannula to dislodge air.
Continue under ‘prime’ setting until the air has been vented, and then replace the
distal cap.
Step Eighteen
The LifePort will bleep and shut off automatically. If the system does not stop,
re-check for air bubbles/ leaks and re-prime. You will not be able to progress unless
all air is removed and all leaks are stopped.
10
Initial Perfusion
Set perfusion pressure using + and – keys. Normal pressure 40 mmHg giving a flow
rate of 40 – 60 ml/min (Pressures can only be set while in ‘wash’ or ‘stop’ mode).
Press ‘infuse’ through the sterile drape and the pump will slowly increase its speed
until preset pressure is achieved. Check the outer display for temperature, flow,
vascular resistance and that the transporter is in ‘infuse’ mode.
Check cannula, tubing, flow rate, artery and vein to ensure good flow and
no leakage.
Record date and time kidney placed into LifePort, Initial Flow, Initial Pressure and
Initial temp.
Replace inner lid and leave sterile drape in situ for 5 minutes.
If no problems remove sterile drape. Replace the outer cassette lid and replace the
outer white lid and lock in place.
11
LifePort pump perfusion transporter storage and monitoring
Both transporters when full will be stored in the main theatre corridor next to the
coordinator one’s station, near the photocopier on trolleys/tables or cart.
The transporters must be plugged into mains electricity. The pump will function
normally with battery power, but will not warn of low battery state and will not charge
batteries, each battery will last for 6 hours.
Once pump perfusing the ice will last for 24 hours, please do not open the white top
cover unless absolutely necessary as this will decrease the cold storage time.
If the pump perfusion stops and is deemed unfixable through the donor co-ordinator
and organ recovery engineer the kidney will be safely stored in the transporter for
24hours.
The LifePort transporter will be monitored initially by the Donor Co-ordinator and
then observed 2 hourly by theatre staff until transplanted.
A tick box chart will be available to show that lifeport has been checked for
alarm conditions
A blinking alarm light means that there is a problem detected, often the machine
can remedy itself.
If there is an audible alarm combined with a visual light blinking please
contact the ON CALL Donor Co-ordinator on pager #6555 or via switch.
12
Download and Data analysis
If data needs to be reviewed prior to transplant, perfusion will need to be stopped
30 minutes prior to kidney being required on the back table in the recipient theatre
for review. This will enable data to be downloaded from the LifePort to the laptop for
analysis by donor co-ordinator. The rate of data down load is quite slow (serial
port.) and may take up to 5 minutes to transfer to the laptop.
If data is not needed prior to transplant, the data can be downloaded at a later time
by the donor co-ordinator. (Storage of 5 cases is possible in transporter computer)
13
Removing the kidney from the transporter for transplant
The transporter should be taken into theatre and put on a table or trolley.
When the surgeon is ready, unlatch the top white cover and remove the outer cas
sette lid and place it upside down in a clean area.
Record Final Flow rate, Pressure and Temp.
Press the ‘stop’ button to stop perfusion.
Record time at which the machine is stopped as the time at which the kidney
is removed.
A scrubbed member of the team should cover the transporter with a sterile drape
and remove the inner cassette lid.
Place an empty sterile bowl onto the draped transporter near the cassette.
Remove secure net from kidney.
Disconnect the cannula from infusion tubing and direct tubing to bowl, press ‘prime’
button to flow enough perfusate into bowl to cover kidney, press ‘stop’ button.
Detach cannula from mounts and lift the kidney from cassette and place in
ready bowl.
Once the kidney has been removed from the transporter it can be powered off
and cleaned.
The perfusion circuit and cassette are single use and should be disposed of as
clinical waste.
14
Cleaning
Universal precautions should be used when cleaning the transporter.
CAUTION!
Do not clean the transporter whilst mains power is connected.
Do not immerse the transporter.
Do not allow cleaning solutions to enter the rear panel electrical connectors, the
ventilation holes, or the battery area.
The transporter surfaces should be kept clean, wipe with 70% Isopropanol solution
to clean. Wipe down all exposed surfaces for a minimum of 15 seconds, allow to
air dry. Inspect for damage or deterioration of the surfaces, drain clean and air dry
the ice container between each use.
Return to storage and plug into mains electricity to recharge.
15
Troubleshooting
Most problems that you encounter in operating the LifePort Kidney Transporter will be easily solved.
The first thing to check when troubleshooting the system is to make sure that power is available from
either the batteries or through the power cord plugged into a standard electrical outlet. If the power
light comes on but the Transporter still does not work, check the following troubles, probable causes,
and actions.
Trouble
Probable Cause
Action
No power
Dead batteries and
disconnected from mains
power
Replace with fresh
batteries or plug into
mains. Make sure
batteries are fully charged
before using.
No Power at outlet
Make sure outlet has
power.
Tripped circuit breaker
Reset breaker by pressing
in the button on the
external connections
panel. Call service.
Errors detected internally
by the Transporter
Follow the instructions in
16, Fault Message
Explanation.
Beeping or flashing
LEDs
Trouble
Probable Cause
Action
Missing or incorrect
display elements at
power-on
Failure of displays or
internal computer
Call service.
Leaking perfusate
Loose fitting or defective
Tube set.
Retighten all fittings.
Replace tube set if
defective.
Leaking coolant
Broken container or seal.
Lid not tightened
Tighten lid and look for
leaks. Call service if leaks
cannot be resolved.
Power on, but buttons are
unresponsive
Transporter is internally
locked-up
Power off then on.
Disconnect mains, then
remove all batteries and
replace them. If problem
does not resolve, call
service.
Message Display is
blank. (Unit functioning
properly)
Electrical shock reset
display.
Power off then on.
If display does not return,
call service.
16
Fault Message Explanation
The Transporter has alarms that are sounded when out of range conditions are encountered for
bubbles, pressure, flow, and temperature. The Transporter can recover from many of these errors
and perfusion will automatically resume. The Transporter should enter a failsafe mode if any
unrecoverable fault condition is encountered. Scroll the message display to view all of the fault
conditions. The error indicators will remain to alert the user. To clear the indicators for errors,
which are no longer valid, press the mode button with the blinking LED.
Check the following list of fault messages, possible causes, and recommended actions to determine
how to respond if the Transporter happens to alarm. In most cases the audible alarm can be
cancelled or temporarily muted by pressing the STOP touch pad.
Fault Message
Probable Cause
Actions
Power up test failed
An error occurred during
the Power Up Self Test
1 Power off and then on. If
problem persists, note the
message on the second
line and call for service.
One exception is the
Pressure Sensor Failed
message, see below.
Load Perfusion Circuit
The Tubeframe is not
properly located
1 Make sure that the
Tubeframe is properly
installed and the
Tubeframe Locking Arm is
in the correct position.
2 A sensor failure may
exist; call service.
Check Ice
The Ice Container
Temperature Sensor
is reading above
8 degrees C.
1 Replenish ice.
2 Allow up to 15 minutes
for the sensor to drop to
the proper temperature if
the system was warm prior
to installing a filled Ice
Container.
3 Possible Sensor failure;
call service.
Too Cold or Near Freezing
1 Incorrect coolant; use ice
slush made from regular
water.
2 Environmental
conditions too cold; move
transporter into a warmer
environment.
3 A sensor failure may
exist; call service.
Fault Message
Probable Cause
Actions
Too Much Pressure
Pressure Sensor is
seeing higher than
expected values.
1 High G forces are
being created during
transit; cushion or reduce
impact.
2 A Pump, Valve or Sensor
failure may exist;
call service.
Can’t Reach Pressure
Pump cannot achieve the
set arterial pressure.
1 Leaking cannula or
artery; visually inspect
and correct all leaks
under aseptic conditions.
2 Leak in Perfusion Circuit;
tighten loose fittings,
replace circuit if leaking.
3 Low resistance kidney;
no action for maximum
flow or reduce the set
pressure.
4 Clogged filter; replace
circuit or, if available,
replace filter.
Check Tubing
System is sensing
unexpected conditions in
the Perfusion Circuit.
1 Tubeframe not
positioned properly;
check frame and locking
arm position.
2 Kidney not connected;
visually inspect kidney
and cannula, correct all
leaks under aseptic
conditions.
3 A pressure greater than
120% of the set
pressure is persisting;
inspect pressure sensor.
Fault Message
Probable Cause
Actions
inspect pressure sensor.
and call service.
4 Fluid pressure is
not equalizing during
non-infuse modes;
check for arterial and
venous occlusions, check
valves and call service.
Occlusion
System is sensing
unexpected pressures
during Infuse.
1 Blocked Infuse Line
tubing or twisted or
occluded artery; find and
remove blockage
or untwist.
2 Kidney has resistance
over 3 mm Hg/ml/min;
consult supervising
physician.
Bubbles
System becomes unable
to remove air without
user intervention.
1 Air bubble in the Infuse
Line; reprime the circuit
and kidney, under aseptic
conditions.
2 Air is persisting in the
upstream bubble
detector; check Perfusion
Circuit for leaks and loose
fittings.
Clogged Filter
Filter may be clogged
1 Filter is restricting flow;
replace Circuit or,
if available, replace Filter.
2 Pump error; call service.
Fault Message
Probable Cause
Actions
Can’t Reach Pressure
Only 4 hours of battery
life remaining: 2 hours of
infusion plus 2 hours of
temperature monitoring.
1 Low battery power
remaining; plug into mains
power or exchange for
replenished batteries
Sensor Error
System becomes unable
to interact with pressure
sensor properly.
1 The pressure sensor has
become disconnected;
reconnect pressure
sensor.
Pressure Sensor Failed
2 The Transporter is
unable to set the
overpressure alarm
setpoint; call service.
Pump Error
Pump is not responding
normally.
1 Pump failure; call
service.
???? (in battery status)
Computer has lost
communication with
batteries.
1 Operate Transporter with
Mains power; call service.
2 Pump will function
normally on with battery
power, but will not warn of
low battery state and will
not charge batteries.
3 Battery status can be
checked by pressing
on/off button on battery
indicator. A fully charged
battery will last for
approximately 6 hours.
Appendix 1
Lifeport Kidney Perfusion
Transporters Data Chart
Perfusion Equipment
Patients Hospital Number
LifePort Serial Number:
Located on rear of machine
Kidney
Left
or
Right
Perfusate used:
Perfusate lot number:
Perfusate expiration date:
Lot number of circuit used:
Circuit manufacture date:
Initial Data
Date organ placed into Transporter:
Time organ placed into Transporter:
Initial Flow:
Initial Pressure:
Initial Temperature:
Celsius
Ending Data
Date organ removed from Transporter:
Time organ removed from Transporter:
Final Flow:
Final Pressure:
Final Temperature:
Celsius
Appendix 2
PROCEDURE
Controlled Non-Heart
Beating Organ Donation
PROCEDURE Controlled Non- Heart Beating Organ Donation
SETS
EXTRAS
TIES / SUTURES
Basic Set
Large Balfour
Major Set
Double Bowl Set
Arterial Set
Kidney Perfusion Tray
Fingerswitch
diathermy
Giving set
Extension set
Sloops
Suction tubing x 2
Yankuer sucker
8” bowls x 2
Double balloon
Aortic perfusion
catheter
Heavy Mallet
10ml syringe x2
5ml syringes x2
Drawing up needle
Dilute radiographic
contrast medium
2/0 Poysorb ties
LL223
BLADES
No 11
LINEN
Major Abdo Linen
PREP
2/0 Ethilon on hand
needle W795
Videne Antiseptic
POSITION
OTHER INFORMATION
Supine
Operating table: attach extension at bottom
end and rotate table 180 degrees (making foot
end head end now) if x-ray needed.
ON SIDE
Finochetto
LifePort machines & circuits need to be on a
trolley in theatre.The packing of the kidney
remains the responsibility of the Transplant
Co-ordinator weather using standard box
storage or Lifeport pump perfusion.
All specialist equipment will be stored in
the room opposite the co-ordinators desk.
Fluids
2x 1L Wisconsin (UW)
2x KPS1 perfusion fluid
4 x 1L N/Saline
4x 1L Marshalls HOC (from blood fridge). 4x 1L of frozen crushed N/Saline.
Please fill blue chill box ¾ full with ice found in blue bags in freezer & store all
fluid in this in theatre.
Heparin 5000iu to be added to first litre of perfusion fluid.