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Policies,Clinical,UWHC Clinical,Department Specific,Hemodialysis

Hemodialysis treatment using the Fresenius 2008 Series (K & T) Machines (3.10)

Hemodialysis treatment using the Fresenius 2008 Series (K & T) Machines (3.10) - Policies, Clinical, UWHC Clinical, Department Specific, Hemodialysis

3.10

University of Wisconsin Hospital and Clinics
Inpatient Hemodialysis
Department 55400
TITLE: Hemodialysis treatment using the
Fresenius 2008 Series (K & T) Machines
POLICY #:3.10
REVISED: July 18, 2017
Page 1 of 9
Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Arjang Djamali, MD
I. PURPOSE
Dialysis Nurses and Technicians will be able to safely set-up the Fresenius 2008 series machines
(2008K & 2008T) for the purpose of Hemodialysis, assuring that the extracorporeal circuit is
free of air, sterility of all connections are maintained, machine set-up parameters match the
dialysis prescription and dialysate is being supplied to the dialyzer in a counter-current fashion
delivering the most effective dialysis treatment possible.
Dialysis Nurses and Technicians will be able to safely initiate, re-initiate and discontinue dialysis
using the Fresenius machine.
II. POLICY
A. Refer to the Fresenius operator’s manual for specific information concerning dialysis
machine functions.
B. Registered nurses or Dialysis Patient Care Technicians will prepare, initiate, reinitiate
and discontinue dialysis treatment after demonstrating competency.
C. The Registered nurse or Dialysis Patient Care Technician will be responsible for
verifying the machine is disinfected, prepared and tested per manufacturer’s
recommendations. Dialysis treatment will not be initiated unless the equipment and
monitor systems are functioning properly and treatment will commence within 6 hours of
preparation.
D. The Dialysis Patient Care Technicians and the Registered nurses are responsible for
inspecting dialysis machines, dialysate solutions, tubing, and dialyzers for defects and
expiration dates prior to initiating dialysis.
E. The Registered nurse will be responsible for verifying the machine is prepared per
physician’s orders prior to initiating dialysis.
F. Dialysate:
i. Only acid and bicarbonate concentrations approved for the proportioning pump
settings of the Fresenius and Gambro machines will be used. Current
proportioning pump settings are for 45x solutions.
ii. Unless there is a physician’s order to vary the concentrations; our baseline
bicarbonate will be set to 35 meq/L and sodium at 139 meq/L.
iii. Machine conductivity will be verified as correlating to an independent meter.
Dialysate conductivity, pH and temperature will be verified as within range,
13. 5 to 14.5, 6.5 to 7.5, and 35-37º C, respectfully.

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 Prior to the initiation of the first dialysis treatment, informed consent is required. See
Hemodialysis Departmental Policy 1.1 Informed Consent for Dialysis and Related
Procedures for details regarding consent.
 Hepatitis B and C infectious disease status will be determined with the first dialysis
treatment and if unable to determine transmission status screening labs will be drawn per
Hemodialysis Departmental Policy 5.0 Hepatitis B and C Screening and Hepatitis B and
C transmission prevention in Hemodialysis.
 Hand hygiene will be performed, aseptic technique used when making any blood tubing
connections and standard precautions, i.e., gloves, protective eyewear, isolation gown,
mask or a chin length face shield must be worn if there is a risk of splash or spray of
moist patient materials.
 Inspect all clamps and blood pump segment for proper occlusion; visualize the patient’s
access and blood tubing for secure connection and/or the presence of air.
 Dialysis delivery system alarms will be monitored throughout the dialysis procedure. See
Hemodialysis Departmental Policy 3.9 Patient assessment and monitoring before, during
and immediately after hemodialysis.
 Occasionally, dialysis may be interrupted according to the nurses. In these instances the
extracorporeal system can be recirculated for a maximum of 20 minutes. Every effort
should be made to return the blood prior to initiating recirculation.
III. EQUIPMENT
A. Fresenius machine
B. Medi-system blood tubing: Note: Low Volume tubing is not airless meaning it is more
prone to clotting. Consider using heparin or saline flushes. Refer to the hemodialysis
order set.
Tubing   PRIMING VOLUME Blood Pump Segment (mm)  
Low Volume 2.6 mm   29 ml  2.6 mm 
Low Volume 4.8 mm   52 ml  4.8 mm 
Low Volume 6.35 mm   82 ml  6.4 mm 
Adult Streamline Airless System set  109 ml  8 mm 
C. Prescribed dialyzer
DIALYZER  Membrane/Sterilant   PRIMING  Type  SIZE  (m
2

F3  Fresenius Polysulfone ® /Ethylene Oxide   24 ml  Low Flux  0.4  
F4  42 ml  Low Flux  0.7  
Revaclear  Polyarylethersulfone, Polyvinylpyrrolidone 
(Poracton™)/Steam   
84 ml  High Flux  1.4  
Revaclear Max  100 ml  High Flux  1.8  
Asahi Rexeed 21S   Polysulfone / Gamma Rays   
Use for people with “allergic” reactions  
112 ml  High Flux  2.1  
D. 1 Liter normal saline
E. Prescribed Acid concentrate solution
F. Prepared Bicarbonate concentrate solution
G. Blue plastic hemostat clamps
H. Recirculator/prime connector
I. Secondary IV tubing and Buretrol® as needed for low volume patients
J. Personal protective equipment
K. Three-way stopcocks for pediatrics

Page 3 of 9
IV. PROCEDURE LIST
A. PRIMING FRESENIUS 2008 series machines
B. See UWHC Nursing Policy 1.28AP Care of the Hemodialysis/Apheresis Catheter for
detailed information on care, maintenance, and use of a hemodialysis catheter
C. See HD Policy 6.2 Insertion and Removal of Hemodialysis Access Needles for
detailed information on care and use of an arteriovenous hemodialysis access.
D. PATIENT CONNECT FRESENIUS 2008 series
E. PATIENT DISCONNECT FRESENIUS 2008 series
F. UF AND SODIUM PROFILES
G. RECIRCULATION
V. PRIMING FRESENIUS 2008 Series Machines
1. Press POWER key on the control panel. Be sure water is on.
Control Panel Settings. Both 2008K & 2008T series machines are calibrated for use with
Medi-systems tubing according to the manufacturer’s settings. There is no need to change
modules on the machine as long as you are using Medi-systems tubing. The 2008K (#18 & #20)
machine also has a pediatric mode setting. This mode changes the blood pressure cuff inflation
and alarm parameters. It also enable higher ultrafiltration removal rates at a lower blood
pump speed (i.e. less than 90 cc/hour) Please refer to p. 153 in the Fresenius manual for more
information.
2. Verify the physician’s prescribed tubing size and dialyzer and adjust the control panel
machine settings according to the physician’s prescription.
a) Blood pump calibration – The pump segment size is printed on each tubing package.
Refer to the table below to the determine blood pump settings according to tubing size:
Medisystems TUBING Size  PRIMING VOLUME Blood Pump Segment (mm)  
Low Volume 2.6 mm   29ml  2.6 mm 
Low Volume 4.8 mm   52 ml  4.8 mm 
Low Volume 6.35 mm   82 ml  6.4 mm 
Streamline Airless system  109 ml  8 mm 
To change the pump segment setting:
1. Open the Blood pump door.
2. Press and hold BOTH the up and down arrows until the setting flashes.
3. Press the up or down arrow to scroll to the setting that matches the size of the blood
chamber. Closing the Blood pump door will activate/confirm the setting.
b) High Flux Option – Find the Test & Options screen located at the bottom of the screen.
Change setting High Flux to ON depending on the dialyzer prescription.
Refer to the table below to the determine settings according to dialyzer type.
DIALYZER  Membrane/Sterilant   PRIMING  Type  SIZE  (m
2

F3  Fresenius Polysulfone ® 
/Ethylene Oxide  
24 ml  Low Flux  0.4  
F4  42 ml  Low Flux  0.7  
Revaclear  Polyarylethersulfone, 
Polyvinylpyrrolidone (Poracton™)/Steam  
84 ml  High Flux  1.4  
Revaclear Max  100 ml  High Flux  1.8  
Asahi Rexeed 21S   Polysulfone / Gamma Rays   
Use for people with “allergic” reactions  
112 ml  High Flux  2.1  
c) Pediatric Mode Option - Find the Test & Options screen located at the bottom of the
screen. This will change the blood pressure inflation and alarm parameters for pediatric
patients. Switch to ON to enable.

Page 4 of 9
3. Plug acid wand into acid concentrate. Should hear and feel a ‘snap’. Verify the acid
concentration jug/wall port against the physician order.
4. When “Select Program” screen appears, press ‘Dialysis’ to enter Dialysate screen.
5. From the Dialysate screen, confirm the concentrate that matches the physician’s
prescription (upper left corner).
a) Press ‘Conc’ to open sub-screen. Use the arrow ▲▼ keys to highlight in the correct
concentrate and then press the ‘Confirm’.
5. Select Base Na+ and Bicarbonate buttons and enter the prescribed value with the keyboard
entry keys and confirm. Remember to always put it back to the baseline setting of 139
Sodium and 35 of Bicarbonate after every dialysis treatment.
6. Press ‘Home’ screen. The “Home” screen will appear on the monitor.
7. Connect to bicarbonate source.
a) 2008T Machine using the bibag, make sure that the blue bicarbonate connector is
inserted into the machine’s bicarbonate port and prepare bibag: Remove white plastic
seal from underneath the water and bicarbonate nozzles of bibag. Invert the bibag and
check to make sure the particulate filter is in place (Figure 1). Facing the machine open
the bibag door located on the left lower side by lifting up the dark grey handle.
Figure 1. In line particulate filter Figure 2. Bibag placement on the machine housing.
b) With the white bibag handle facing outward, hang the bag by inserting the inlet and
outlet nozzles (Figure 2). Close the door making sure it latches firmly with two audible
click as it closes.
c) To use jug as a bicarb source: Connect the bicarb wand to the bicarb jug. Should hear
and feel a ‘snap’ upon connection.
Medi-systems tubing sets have different configuration based on size, refer to manufacturer’s
package insert for details. 2.6 mm and 4.8 mm tubing sets do not have arterial drip chambers
or arterial pressure monitoring lines, the 6.35mm tubing set has both. All Medi-tubing sets
regardless of size have venous drip chambers and venous pressure monitoring lines.
Alternatively, Streamline Airless tubing uses arterial and venous pressure pods to monitor
arterial and venous line pressure.
8. String the arterial line, snap arterial drip chamber if present in holder with the saline “T”
between the two line holders. Press and hold the ‘Start/Stop’ key to thread blood pump
segment. Place the patient end in the priming bucket (all small line clamps should be
closed), blood pump segment “slack” should be at post end of pump. (Right side).

Page 5 of 9
9. Place the venous line on machine, adjust the venous drip chamber in the air detector with
the filter just below the silver pads, and place the patient end in the priming bucket (all
small line clamps should be closed). DO NOT THREAD THROUGH LINE CLAMP.
10. Attach saline line and unclamp. When air is purged from the patient end of arterial line,
clamp thumb clamp. Fill arterial drip chamber if present by opening the monitor line clamp
(long line) and allow chamber to fill 2/3 full, re-clamp line.
11. Finish priming arterial line by pressing the ‘Start/Stop’ key on the blood pump (green
light ON) and then press the ‘Prime’ key. When saline reaches the end of the line, press
the ‘Start/Stop’ key to stop blood pump (green light OFF). Connect arterial line to
dialyzer.
12. Place dialyzer venous end up and attach venous line to dialyzer.
13. Press the ‘Start/Stop’ key to turn on blood pump (green light ON) and allow the preset
amount of 300 ml to run through the dialyzer. DO NOT fill venous drip chamber until
finished. The Prime light will go out when this is done.
14. Thread venous line through line clamp and optical detector. Attach the venous pressure
monitoring line to the pressure port and unclamp. Press the ‘Prime’ key and allow the
venous drip chamber to fill. Prime will stop when level detector senses fluid. Use the
▲▼keys to fill chamber to 2/3 full. Re-clamp the monitor line and disconnect from
machine. Press the ‘Start/Stop’ key to stop blood pump (green light OFF) and press
‘Reset’ to clear all alarms.
15. Connect patient ends of bloodlines in preparation for recirculation. Open blood line thumb
clamps. Clamp saline line.
16. Before beginning dialyzer recirculation and prior to each patient treatment, the machine
should undergo Pressure and Alarm tests to ensure that it is functioning properly. Prior to
treatment alarms and pressure test must be completed.
a) Before starting the test sequence, ensure that the dialysate lines are connected to the
shunt with the interlock door closed.
b) The machine must be free of any alarms.
c) Arterial and venous monitor lines are clamped and removed from the pressure ports on
machine.
d) The blood pump should be off. (Green light OFF).
e) Stable conductivity.
18. Starting the Test, from the Test & Options screen, press ‘Both Tests’. Press the
‘Confirm’ key. When the machine passes all tests, a message “Test Complete” appears in
the status box. Press ‘Reset’ to clear the message. Proceed to “Recirculation” when
testing is complete.
19. Prepare to Recirculate Machine: Prior to connecting the dialyzer connectors to the
dialyzers the Conductivity and PH should be checked using a Dialysate handheld Meter.
a) Connect dialyzer connectors to dialyzer. Fill the dialysate compartment completely then
position the dialyzer in the holder with the venous end UP.
b) Attach the arterial and venous monitor lines to the pressure ports, open line clamps.
Low volume tubing needs a transducer attached to the arterial and venous monitor
lines before attaching to the pressure ports It is also important to adjust the fluid level
in the drip chamber to reduce the incidence of backflow into the monitor line.
c) Be sure the machine is free of Alarms. From the Test and Options screen, press
‘Prime/Recirc’ until the (X) is in the ‘on’ box, then press ‘Confirm’. Open saline line

Page 6 of 9
and verify that there is enough saline for recirculation. (200 mL)
Note: For Low volume/pediatric patients attach a Buretrol between the saline line and
the saline bag and prime the Buretrol chamber with at least 100 ml of saline.
d) Press the ‘Start/Stop’ key to turn on blood pump (green light ON). And adjust QB to
desired flow. Top of screen should say “Recirculating”. ( If message is “Recirc
Interrupted” be sure UF is turned on) When Recirculation appears Press ‘Reset’ to
clear message.
e) UF removed must be zero before you start a treatment by turning off the UF (right side
key) and press ‘UF Removed’ box and zero it out. Press Confirm
20. PROCEED TO PATIENT CONNECT.
VI. PATIENT CONNECT FRESENIUS 2008 Series
VII. PATIENT DISCONNECT FRESENIUS 2008 Series
1. Before proceeding to connect the patient validate treatment time, target loss, ultrafiltration
rate, dialysate rate and temperature against the physician’s order.
2. Turn off blood pump. Clamp the arterial, venous and saline lines. Verify the patient’s
access, i.e., arterial and venous needles/lumens are clamped.
3. Disconnect arterial and venous blood lines. Keep re-circulator connector on venous line.
4. Connect the arterial line to the patient’s arterial needle/lumen. Unclamp the arterial lines.
5. Remove re-circulator connector from venous line and connect the venous line to the
patient’s venous needle/lumen. Unclamp the venous lines.
6. Turn on the blood pump and monitor the venous blood line for blood to be sensed.
7. Begin treatment by pressing the Treatment Clock and then Confirm. The message,
“Dialysis” will appear.
8. Increase the blood pump speed to the prescribed blood flow rate, monitoring the venous
and arterial pressure as increasing the rate.
1. Once treatment complete, press the Treatment Clock and then Confirm. The message,
“Dialysis Paused” will appear.
2. Turn off blood pump.
3. Clamp the arterial line and the patient’s arterial access line. Disconnect the saline line
from the system and connect it to the arterial line utilizing the priming connector. Flush
the patient’s arterial access per protocol
4. Unclamp the saline line and the arterial line.
5. Turn on the blood pump and return the patient’s blood. .
6. Clamp the venous line and patient’s access line to disconnect the patient from the
machine. Flush patient’s access per unit protocol
7. Remove blood lines from the machine. Remove dialysate lines and place in the interlock
shunts located at the right side of the machine. Removing the blue dialysate connector
from the filter and placing it on the shunt interlock will allow the dialysis filter
compartment to empty. When filter is empty, connect the red dialysate connector in the

Page 7 of 9
VIII. ULTRAFILTRATION PROFILES and SEQUENTIAL DIALYSIS (UF ONLY)
A. Ultrafiltration profiles
B. Sequential Dialysis – sole ultrafiltration with no dialysate flow.
shunt interlock. Close the shunt interlock door when both dialysate hoses are returned to
the shunt interlocks: blue to blue and red to red.
8. 2008T Machine using the bibag, the bag can be emptied manually at the end of treatment,
or alternatively the “Empty bibag,” button on the upper right hand of dialysate screen can
be used. To auto empty select the Empty bibag, button and confirm. When bibag is empty
of fluid, the Status Box will display the message “ bibag: Emptied.” Lift up on dark-grey
bibag door handle to open and dispose of spent bag. Close the door securely making sure
that the door latches into place with two clicks.
9. Proceed with new set up or disinfection procedure
There are 8 possible pre-programed ultrafiltration (UF) profiles to choose from. To view the
available UF PROFILES
1. Touch the UF Profile button on the HOME screen. The profiles are displayed graphically
on this screen.
a) “None” profile performs ultrafiltration at a constant rate. It does NOT mean no
ultrafiltration.
To set a UF PROFILE
2. Select one of the profiles by pressing the button graphically representing the desired
profile. An enlarged view of the selected profile will appear on the right side of the sub-
screen.
3. Enter the desired UF Goal and UF Time values using the arrow ▲▼ keys, if not
previously entered. Then press the ‘Confirm’button. This will calculate the maximum
ultrafiltration according to the chosen UF profile.
a) If the maximum UF rate is too high, a message will appear in the dialog box. Change
the profile, UF Goal or UF Time accordingly.
4. Once all ultrafiltration parameters are satisfactory, press ‘Confirm’.
To set sequential ultrafiltration
1. From the HOME screen, set the UF Goal and UF Time accordingly. These parameters
should be set to include both treatment and sequential dialysis goals and time.
To start Sequential UF
2. Turn off the Dialysate Flow by pressing the Dialysate Flow on/off key upper right corner
of the control panel. Note: The yellow light will flash in this mode.
3. Touch the Dialysate Flow display and using the arrow ▼ keys, to enter SEQ. Then press
the ‘Confirm’. This will deactivate the “Flow off” warning for the next 60 minutes. The
Dialysate Flow button will display “SEQ”
4. After 60 minutes an alarm will sound. Press Reset to continue sequential UF.
To start Treatment
5. Touch the Dialysate flow button on the HOME screen, set the prescribed dialysate flow
rate using the arrow ▲▼ keys. Then press the ‘Confirm’.

Page 8 of 9
IX. SODIUM VARIATION SYSTEM (SVS) PROFILE
A. There are 3 basic profiles available: Step, Linear, and Exponential.
X. RECIRCULATION
6. Start the dialysate flow by pressing the Dialysate Flow on/off key
Note the machine is not delivering dialysate to the dialyzer. However, the machine must be in
conductivity to perform sequential ultrafiltration i.e., needs to be plugged into acid & bicarb.
To view the available SVS PROFILES
1. Touch the SVS Profile button on the HOME screen. The profiles are displayed
graphically at the top of this screen.
a) “None” profile maintains the sodium level at the constant base rate.
To set a SVS PROFILE
2. Select one of the profiles by pressing the button graphically representing the desired
profile. An enlarged view of the selected profile will appear on the right side of the sub-
screen.
3. Press Start Na+ and enter the starting (maximum) sodium (Na+) value using the
numbered key pad.
4. Press Base Na+ and enter the final sodium concentration value to be reached at the end of
the SVS profile using the numbered key pad.
5. Press SVS time and enter the running time for the SVS profile using the numbered key
pad. Then press the ‘Confirm’.
Return the blood if at all possible prior to initiation of recirculation.
1. Press the TX Clock button on the HOME screen. Then press the ‘Confirm’ to pause the
treatment.
2. Press the blood pump ‘Start/Stop’ key to stop the blood pump.
3. Disconnect the arterial and venous blood lines from the vascular access in an aseptic
manner and connect them together using a sterile recirculation connector.
4. Unclamp the saline line.
5. Press the blood pump ‘Start/Stop’ key to start the blood pump and set the blood flow rate
at 150-200 mL/min. An audible alarm will sound every two minutes while the TX clock
is paused.
To reconnect the patient.
6. Press the blood pump ‘Start/Stop’ key to stop the blood pump.
7. Clamp the saline line.
8. Aseptically reconnect the arterial and venous bloodlines to the patient’s access.
9. Press the blood pump ‘Start/Stop’ key to start the blood pump and adjust the blood flow
rate to the prescribed flow rate.
10. Press the TX Clock button on the HOME screen. Then press the ‘Confirm’ to resume
the treatment.

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XI. RESOURCES
1. Fresenius T Operator’s Manual
2. Gomez, N. J., (Ed). (2011). Nephrology nursing scope and standards of practice (7
th
ed.,
pp. 123-144). Pitman, NJ: American Nephrology Nurses’ Association
REVIEWED:
CSA 7/12/17