Copyright © 2015 NIKKISO Co., LTD. All rights reserved. Aquarius System Tips for improving Aquaset life US English version This presentation refers to ICU team choices of heparin or no anticoagulant during Continuous Veno-Venous Hemofiltration therapies via the Aquarius System. PM-0063-11/2015-1 Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Optimize Vascular Access Consider using a high flow silicone vascular access catheter that does not have “kink memory” , and with an appropriate length for the chosen site. Avoid attaching the Aquarius to a catheter with poor flow. For example, being able to withdraw 20ml of blood in 6 seconds or 10ml of blood in 3 seconds without hesitancy or interruption may help a catheter assessment. Consider rotating the hub of the catheter 90° so that the holes on the access lumen are facing the flow of blood, not against the vessel wall (you may need to momentarily stop the blood pump to do this). Consider the patients intravascular volume. Even though the patient may be fluid overloaded, if their intravascular space is dehydrated, there may be poor flow through the catheter which will encourage clotting. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Optimize Anticoagulation High return pressure is one sign of under anti-coagulation. The blood pump wants to push the blood through the return chamber where partially formed blood clots may increase in size, making it difficult for the blood to squeeze through. A routine of regular observation, followed by a check of the patient clotting, and adjustment of anticoagulant where indicated, may prevent early return chamber clotting. Consider increasing the proportion of pre-dilution if anticoagulation adjustment is not indicated. For example: altering the pre-dilution to 90 % and reducing post-dilution to 10 % may thin the blood passing through the filter and reduce the effects of haemoconcentration. A gain in lifespan may be offset by a small loss in clearance, easily adjusted by using the Renal Dose display. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Proactively Prevent Clotting in the Set Use recirculation and reprime to remove any unwanted micro-bubbles in the Aquaset. Careful observation after lining and priming may identify areas of concern. Keep the level of the blood in the return chamber more than half full. This reduces blood-to-air contact and therefore unwanted blood clotting in the return chamber. As a clot forms in the return chamber it may block the outflow. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Proactively Prevent Clotting in the Haemofilter Keep the filtration ratio below 25 %. Filtration ratio is a measure of hemoconcentration in the filter (filtrate removed as a percentage of blood flow). It is how much blood is going into the filter compared with how much ultrafiltrate is taken out. The target blood pump speed in the programming guide aims for longer Aquaset life by using a lower filtration ratio. The minimum blood pump speed allows the blood pump to operate well, without clotting off the filter. The lower the filtration ratio the longer the filter is likely to last. Considering an alternate therapy may also be a relevant choice. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Proactively Prevent Clotting in the Haemofilter The faster the blood pump the lower the filtration ratio. Consider increasing the blood pump speed by 10 -15 % of the minimum, where the clinical situation permits. When connecting the patient, delay starting the treatment pumps until the target blood pump speed has been achieved. This will prevent unnecessary haemoconcentration at the beginning of treatment. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Proactively Prevent Clotting in the Hemofilter Re-circulate for 15 to 20 minutes before connecting the patient. Recirculation soaks the filter fibres and pushes out air bubbles trapped within the fibres. Saturating the filter fibres opens them up, improving the flow of blood through them, the absence of micro- bubbles gives less opportunity for early clotting. A recirculation time of between 15 and 20 minutes allows this process to occur. The Aquaset is intended for 72 hours of use, recirculation time is included. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Get the best from your Aquaset! Aquaset life in well-managed regular therapies may exceed 45h. Vascular Access is still King! Optimizing Anticoagulation. Be proactive! Optimizing Blood flow. Adjusting Therapy parameters. Sharing best practice - Top tips, Advice, Hints. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.

Copyright ©2015 NIKKISO Co., LTD. All rights reserved. Aquarius System Questions and Discussion Copyright ©2015 NIKKISO Co., LTD. All rights reserved.

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Copyright ©2015 NIKKISO Co., LTD. All rights reserved. AQUARIUS system NIKKISO Europe GmbH Desbrocksriede 1 30855 Langenhagen Germany AQUAMAX hemofilter Nikkiso Belgium bvba Industriepark 6 3300 Tienen Belgium AQUALINE tubing Haemotronic Via Carreri, 16 41037 Mirandola Italy CITRASETRCA Assembled by Haemotronic Via Carreri, 16 41037 Mirandola Italy AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd. Copyright 2015. All rights reserved. Copyright ©2015 NIKKISO Co., LTD. All rights reserved.