Introduction
Note: For ease of reference throughout this document: The HCP01 AV Loop Pump will be referred to as the pump. The HFW1000 Fluid Warmer will be referred to as the Bag Warmer. The HCS3011 AV Loop Kit will be referred to as the AV Loop Kit. The AV Loop Set will be referred to as the AV Loop.
Warm 500 cc to 1000 cc normal saline in Bag Warmer (warming usually takes 20-30 minutes)

Have available:

100 cc heparinized saline 500 ml or 1000 ml normal saline bag (2) 3-way stopcocks 10ml and 30ml syringes AV Loop Kit

Check that:

Arterial and central venous lines are functioning well Arterial extension set priming volume is < 0.5 ml; otherwise, substitute with a Transonic HSC3002 extension set with reposition of the hospitals extension set to the side port of the 3-way stopcock. Central venous line (including femoral) is a non-silicone catheter and the largest lumen is available for connection to the AV Loop (20G-14G). Vital medications should not be infused through this port when used with an AV Loop.

Warnings:

Refer to COstatus Operators Manual for complete description of COstatus Warnings and Operation. Arterial pressure monitoring will be temporarily unavailable during the measurement (approximately 6-8 minutes).
COstatus, Transonic, and Transonic Systems Inc. are registered US trademarks of Transonic Systems Inc., Ithaca, NY 14850 USA. All rights reserved. Any reproduction or misuse of such trademarks is strictly prohibited without Transonic Systems express written consent.

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QRG-COstatus-Rev B

ARTERIAL CATHETER

Radial, Femoral, Brachial, Pedal etc.

CENTRAL VENOUS CATHETER

Jugular, Subclavian, Femoral
Central Venous Catheter Central Venous Pressure

Blue Tubing Segment

Venous Sensor Arterial Catheter

Hospital Extension Set

Injection Line Injection Syringe Redirection Line Redirection Syringe

Red Tubing Segment

Arterial Pressure
Arterial Sensor Flush Line AV Loop Set

COstatus Monitor HCM101

AV Loop Priming Volume: Injection Volume: Maximum: Pump Rate: Measurement Time: ~5 ml 0.5 - 1 ml/kg 30 ml 8-12 ml/min 5 - 8 min

Flush Syringe

HCP01 Pump
Fig.1: Schematic showing the AV Loop with connections to the patients existing arterial and central venous catheters.
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Priming Guide

Use aseptic technique Use heparinized saline

Procedure

1. Fill a 30 ml Flush Syringe from AV Loop Kit with heparinized saline. 2. Connect Flush Syringe to the Flush port. Prime the AV loop sequentially (Fig. 1). a) to Arterial Connection (1) by loosening the red cap at end of red-colored arterial segment. Close when the saline drips out. b) to Redirection Port (2) until fluids drip out of vented cap. Then close the 1-way stopcock to the AV loop. c) to Venous Connection (3) by loosening the blue cap at end of Venous segment. Close when the saline drips out. d) to Injection Port (4) by connecting the 10 ml Redirection Syringe (in the AV Loop Kit) to the Injection Port. Prime with 2 ml heparinized saline. Make sure that the AV Loop is bubble free and not leaking.
Fig. 1: The AV Loop Set is primed in 4 steps as follows: to the arterial connection, to the redirection port; to the venous connection and to the injection port.
3. Remove the 10 ml Redirection Syringe from the Injection Port, discard collected bubbles and connect the syringe to the Redirection Port. 4. Close all stopcocks

AV Loop Quality Check

1. 2. 3. 4. 5. Load AV Loop cassette into pump. Open stopcocks to Flush Syringe and loosen the blue cap at end of the venous segment. Start pump. Inspect while fluid drips out. Stop the pump and close the blue cap. Close Flush Port. Make sure that the AV Loop is bubble free and is not leaking.

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Connecting AV Loop to a Patient
Use aseptic technique Check that the arterial and central venous lines are functioning well Ensure bubble-free connection
1. Arterial Connection: 1) Connect the AV Loop in a straight line to the arterial catheter (Fig. 1). 2) Check the size of the hospital extension set. a) If priming volume is < 0.5 ml (Fig. 1), use the existing hospital extension set. b) If priming volume is > 0.5 ml , substitute the hospital set with a primed Transonic HCS3002 Extension set (Fig 2). Move the pressure monitor line to a side connection of the 3-way stopcock. c) Close 3-way stopcock to AV loop. 2. Venous Connection (Fig. 3): Connect AV Loop to the side connection of the central venous catheters distal port (the port closest to the patient with the largest lumen). This distal port should not be used for infusing vital medications when used with the AV Loop. 3. Apply Arterial and Venous Sensors: Open sensors and apply petrolatum to grooves in the sensors. Then place sensors on the respective red and blue AV Loop segments. Make sure that the arrows on the sensors point in the direction of flow.
Manifold for infusing vital medications
Fig. 1: The < 0.5 ml hospital extension set connects directly through the straight port of a 3-way stopcock to the AV Loop.

Venous Line

No extension tubing
Connect AV Tubing Set to port with largest lumen closest to catheter.

Central Venous Catheter

Fig. 3: Central venous catheter connection. Fig. 2: The > 0.5 ml hospital extension set is moved to a side port of the three-way stopcock and a Transonic HCS3002 Extension Set connects directly through the straight port to the AV Loop.
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Conducting Measurements

2-3 bolus injections are recommended 1. Check that the AV Loop is connected to the arterial and venous catheters and that the arterial and venous sensors are placed on the red and blue segments of the AV Loop, respectively. 2. Start the monitor and follow the step-by-step on-screen prompts. Note: Arterial pressure can not be monitoring during the COstatus measurement (about 6-8 minutes). 3. When the pump starts, observe blood flowing from the arterial to the venous side through the AV Loop. Watch for the appearance of any bubbles in the AV Loop. If any bubbles appear, remove as instructed on page 7. 4. The COstatus System takes two minutes to calibrate. Enter the patients data on the touch screen. When the on-screen traffic light turns green, fill the Injection Syringe (10 ml or larger) with body temperature saline (0.5-1 ml/kg, max. 30 ml) from the Fluid Bag Warmer. 5. Inject the saline as follows (see sidebar): Injection Method DO NOT use excessive force! 1) Open stopcock to Redirection Syringe. Inject with one hand and thumb 2) Connect Injection Syringe to Injection Port. according to the figure and table below. Inject saline quickly and smoothly into the AV Use 10 ml or larger syringe. Loop. 3) Remove Injection Syringe. 4) Close stopcock to Redirection Syringe. 6. For the next injection, repeat step 5 when the traffic light turns green. Fig. 1: Thumb push. Fig. 2: Fist grip. 7. After eight minutes, the user can choose to con- Injection Time tinue measurements for another three minutes. Note: after 11 minutes, the system automatically stops. 8. End the measurement session by pressing the on-screen Stop button. Results will print automatically.

PATIENTS HEART RATE (BEATS/MIN) RECOMMENDED SALINE INJECTION TIME (SECONDS) 3 2

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Flushing and Conserving the Patients AV Loop for Future Use
Make sure that the Flush Syringe has sufficient heparinized saline (15 ml) 1. Open the stopcock to the Flush Syringe and flush the AV Loops arterial side. Observe the blood returning to the patient. Close the 3-way stopcock to the AV Loop. Observe restoration of arterial pressure on the monitor. 2. Refer to your hospitals policy for the handling of blood in the Redirection syringe. 3. Start pump. Observe the heparinized saline flow through the AV Loop to the venous end and into the Redirection syringe. 4. Close the stopcock to the Redirection Syringe until it is filled with 2 ml of heparinized saline. Close stopcock. 5. Stop the pump. Close the venous 3-way stopcock to the AV Loop and the stopcock to the Flush syringe 6. Eject AV Loop cassette from pump. 7. Remove arterial and venous sensors from the AV Loop. 8. The AV Loop can be conserved for up to 36 hours for use on the same patient. The COstatus System can now be used with the next patient. 9. When all sessions are completed, turn off the COstatus System: 1) Pump (release stop button when five beeps have sounded). 2) HCM101 Monitor 3) Fluid Bag Warmer
For repeated session inspect the loop first, before opening stopcocks to patient.
1. Check there are no bubbles in the AV Loop. If bubbles occur, follow the steps below with stopcocks closed to patient: a. Open Flush Syringe stopcock; b. Open Redirection Syringe stopcock; c. Start the pump; d. Remove the bubbles from the AV Loop into Redirection Syringe. 2. Check that there is no tissue or clots in the AV Loop (especially check at stopcock sites). If these substances are present, perform steps a. - d. above. 3. If substance(s) cannot be removed use new AV Loop.
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Pump Stoppage and Removing Bubbles
Pump Stoppage Can Be Caused by the Following: 1. Power supply connection and pump battery charge Q Make sure they are in good condition 2. Bubble detected Q Remove bubbles (see below) 3. Stopcock not open Q Open the stopcock 4. Kinks/clots Q Adjust catheter position and make sure that respective problems are resolved; stabilize the patient when necessary 5. Pump stops during injection a. Redirection syringe not open Q Open Redirection Syringe b. Redirection Syringe is too full Q Fill syringe with only 1-2 ml heparinized saline When you restart the pump, check flow displayed on the screen. It should go up to 10 -12 ml/min. If the problem was not solved or the operator did not open the stopcock, the screen will display [low flow] or [no flow] and will not proceed to the next screen even if the pump has restarted. Stop the pump and fix the problem. Then restart the pump. Removing Bubbles during Measurement 1. If air bubbles are detected during a measurement, the pump stops automatically. 2. Close the venous 3-way stopcock from the AV Loop to the patient. 3. Open the 1-way stopcock to the Redirection Syringe. 4. Push the pumps start button until the bubbles move out of the AV Loop and are collected in the Redirection Syringe. (The pump may have to be restarted multiple times in this process). 5. Stop the pump after visually confirming the bubbles are cleared from the AV Loop. 6. Open the venous 3-way stopcock to the patient. Return any excess blood from Redirection Syringe to the venous side of the patient. Be sure that the bubbles stay in Redirection Syringe. 7. Close the 1-way stopcock to the Redirection Syringe. Start the pump. 8. Replace the Redirection Syringe with a new 10 ml syringe filled with 2 ml of heparinized saline. 9. Continue with the measurement.