Water for Dialysis Part 1: Components - MTFD · Why Water Must be Treated Person on Hemodialysis...
Transcript of Water for Dialysis Part 1: Components - MTFD · Why Water Must be Treated Person on Hemodialysis...
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Water for Dialysis
Part 1: Components
Danilo B. Concepcion, CBNT, CHT-A, FNKF
(714)771-8944
The findings and conclusions in this presentation are those of the
author and do not necessarily represent the views of St. Joseph
Hospital
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•Safety of Water and Dialysis Delivery: The highly-technical nature of dialysis treatments place the patients at significant risk if there is isolated or systemic failure to follow precise procedures.
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Anemia Bone Disease Fever, Chills Hemolysis Hypotension Hypertension Muscle Weakness Metabolic Acidosis Methemoglobinemia with cyanosis Nausea & Vomiting Neurological Deterioration
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Why Water Must be Treated
Person on Hemodialysis
• Blood is exposed to 360+ liters of water/ week
• Dialyzer membrane is thin, non-selective
• Nonfunctioning kidney
• Can experience harm or death from untreated water
Average Person
• Drinks 14 liters of water/week
• GI tract more selective
• Functioning kidney
10 - 14 Liters
350 - 450 Liters
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The Role of Water in Hemodialysis
• Preparation of dialysate
• Reprocessing of hemodialyzers
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How Water is Treated
The municipal or public water supply is made safe for dialysis by use of a water treatment system.
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Sources of Water
• Ground Water
• Surface Water
• Municipal Water
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Types of Contaminants
• Microorganisms
• Organic Contaminants
• Inorganic Contaminants
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Water Treatment Standards
AAMI: Association for the Advancement of Medical
Instrumentation
CMS: Centers for Medicare & Medicaid Services
(Formerly HCFA)
FDA: Federal Drug Administration
State: Each state sets it’s own standards
Facility: Policies and Procedures
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CHEMICAL mg/L
Nitrate 2.00
Zinc 0.10
Copper 0.10
Aluminum 0.01
AAMI STANDARDS
CHEMICAL mg/L
Fluoride 0.20
Chloramine 0.10
Free Chlorine 0.50
Sulfate 100.00
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CHEMICAL mg/L
Barium 0.100
Selenium 0.090
Chromium 0.014
Lead 0.005
Silver 0.005
Thallium 0.002
CHEMICAL mg/L
Cadmium 0.0010
Mercury 0.0002
Arsenic 0.0050
Beryllium 0.0004
Antimony 0.0060
AAMI STANDARDS (cont.)
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AAMI STANDARDS (cont.)
CHEMICAL mg/L
• Calcium 2.0
• Magnesium 4.0
• Sodium 70.0
• Potassium 8.0
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The Water Treatment System Components
• Backflow Preventer
• Temperature Blending Valve
• Booster Pump
• Sediment, Depth, or Multimedia Filter
• Water Softener
• Carbon Tanks
• Micron Filters
• Reverse Osmosis (R.O.)
• Deionization Tanks (D.I.)
• Storage Tank
• Ultrafilters
• Flowpath, Pipes, and Gauges
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The Water Treatment System Components
Backflow Preventer
• Prevents water and/or disinfectants from flowing backward from the dialysis unit into the municipal (public) water supply
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Backflow Preventer
• Prevents reverse flow of water and or contaminants through the valve, which would contaminate the potable drinking water supply.
• Installed, tested by licensed plumber
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The Water Treatment System Components
Temperature Blending
Valve
• Mixes incoming cold water with water from the hot water heater
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The Water Treatment System Components
Booster Pump
• Boosts water
pressure from 40
psi to 60-80 psi
(pounds per
square inch)
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Sediment Filter
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The Water Treatment System Components
Sediment, Depth, or Multimedia Filter
• Designed to catch large suspended particles such as algae, rust, and sand
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Sediment Filter
• What is it and What does it do? – Tank containing several layers of different
media designed to filter sediment particles from city water supply
• How do we Monitor it? – Sediment filter is monitored on daily basis for:
• Pressure drop across filters • Backwash timer heads set to correct time
of day –Re-generated or “backwashed” during
hours of non-operation in order to clean the media
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Sediment Filter
• What do we do if it fails?
– Depending on facility’s “Silt Density Index”, RO may handle short term bypass of this device
• What is the adverse impact on the patient if it fails?
– Failure of this equipment may not effect operation at all, depending on city feed water quality
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The Water Treatment System Components
Water Softener
• Removes calcium and magnesium
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Na+
Na+
Na+ Na+
Na+
Na+
Na+
Na+
Na+
Softener
Resin Bead Ca++
Cl- Cl-
Cl- Cl-
Ca++ Ca+ Ca++ Ca++ Ca++
2Na+
2Na+
2Na+
2Na+ 2Na+
2Na+
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Softeners & Exchange Tanks
For the
removal of
water
hardness
(calcium,
magnesium)
in exchange
for sodium
NaCl
solution
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Softeners and Exchange Tanks
Monitoring
– Record pressure pre and post softener
• At least daily
– Check hardness post softener
• In a.m. and p.m.
• <2 grains hardness (<35 mg/L)
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Softeners
• Shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration – shall be interlocked.
• Shall be measured at the end of each treatment day.
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Water Softener
• What do we do if it fails?
– Softeners may be temporarily bypassed
– Running RO without a softener for prolonged amount of time could cause permanent damage to RO membranes
• What is the adverse impact on the patient if it fails?
– Prolonged failure of water softener can cause failure of RO membranes, and can also cause further patient complications
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The Water Treatment System Components
Carbon Tanks
• Used to remove chlorine and chloramine
• Two Carbon tanks are used in sequence, a “Worker” and a “Polisher”
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SA = 1000 m2/gm or 3280 f2/0.002 pounds
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Carbon Tanks
Iodine number of 900 or higher
Acid washing removes manufacturing debris
Tanks are sized for Empty Bed Contact Time (EBCT).
10 minutes EBCT for chloramine removal
V=(Q x EBCT)/7.48 – 1.2 gal/min EBCT 10 min./7.48 = 1.6ft3
Two tanks in series for total EBCT, worker and
polisher
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Carbon Tanks
Monitoring
– Check total chlorine post first tank
• Before every shift
• Every four hours
– Pre and post pressure
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Carbon Tanks
• What do we do if it fails?
– If breakthrough is noted on primary tank, total chloramine level should immediately be checked after secondary tank
– If there is no breakthrough noted after secondary tank, treatments can continue with increased frequency (at least hourly) of total chloramine monitoring with Medical Director approval for up to 72 hrs
– If breakthrough is noted after secondary GAC tank, treatment must be stopped immediately
– Both tanks must be re-bedded within 72 hrs
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Carbon Tanks
• What is the adverse impact on the patient if it fails?
– Failure of GAC tanks may result in elevated level of chlorine and chloramine in pre-treated water
– Chlorine and chloramine will cause permanent damage to most RO membranes
– Chlorine and chloramine in product water can lead to hemolysis or death
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The Water Treatment System Components
Micron Filters
• Micron filters remove small particulate matter
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Prefilters
Final Barrier against particles or debris that can damage RO pumps and membranes
Head
Flow
Outlet
O-ring
Filter Cartridge
Shell
Flow
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Prefilters
Considerations/Concerns Disposable cartridge with a 3 to 5 micron
filter size
Change prefilter when • 8-10 PSI higher than clean pressure loss
• Or on a routine schedule
Disinfect bowl and head to remove biofilm
AAMI standards require housing to be opaque
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Membrane Element
Permeate Flow
Concentrate
Permeate
Feed Solution
Collection Tube
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Monitors and Controls
Indicators of water quality (conductivity, TDS, resistivity)
Local
Remote
% Rejection (Input - Product / Input) x 100
(V200) Include a means to prevent patient exposure to
unsafe product water, such as diversion of the product
water to drain…
Disinfection lock-out
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V199 – V201 R.O. • 5.2.7 a means to prevent patient exposure to
unsafe product water, such as diversion of the product water to drain… – V200 IG: In the absence of an automatic divert to
drain valve for the RO, facility staff must demonstrate knowledge of the requirement to manually stop water flow to the dialysis machines…
• 6.2.7 chemical analysis – Installation, membrane replacement, seasonal
variations, <90% rejection
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Post Treatment Components
• U.V. Light
• Sub-micron/Ultra-filters
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Ultraviolet Irradiator
UV Lamp
Quartz Sleeve
‘O’ Ring
Quartz Nipple
Plug
Washer
Lamp Harness Assembly
Pilot Light
Power Supply
Kills or alters DNA of bacteria as water passes through UV
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Ultraviolet Irradiator
• UV is a mercury vapor lamp enclosed in a fused quartz sleeve
• Endotoxins may be produced as it kills bacteria
• Ultrafilter recommended after UV for endotoxin control
UF may be placed at points of use
Check LAL
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Ultraviolet Irradiator
• UV Maintenance
Routine cleaning REQUIRED to
retain efficiency
• Lamp replacement
Once per year, not when burns out
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Submicron and Ultra Filters
• Sub micron filter
0.1 through 1.0 microns
• UF filters/Membranes rated by
pore size
Generally .001 through 0.05 microns
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Ultrafiltration (UF)
• Prevents patient from being “final filter”
• Removes Bacteria and endotoxin – Validated medical filter (absolute rating)
– Rated in nominal MWCO
• Problem with decrease in pressure and flow which affects velocity
• Place at points of use: – Dialyzer reprocessing equipment
– Bicarbonate filling station
– Dialysis machine on dialysate