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The Hygienic Chain
The Hygienic Chain
We are pioneers in HD, and we have over a decade of experience in water treatment and uid distribution systems specialized for HD units. In fact, we are the one company that is able to provide every link in The Hygienic Chain. Whats more, ours is the only system proven effective against biolm because every link is designed to resist microbial proliferation and is fully integrated from RO unit to drain.
How choosing the right water treatment system can help prevent biolm
The rst link in The Hygienic Chain is proper water treatment. Treatment requirements vary according to the type of water available in each municipality. Whats more, seasonal variations in water quality exist within each municipality. So its important to contact your municipal waterworks for information on water quality and seasonal variations in your area. Typically, stages for water purication include pre-treatment, softener, and reverse osmosis. While starting with a reliable water treatment system is important, you should be mindful that most of the microbiological contaminants found in HD uid are introduced further down the line, after the RO unit. Purifying water only to have it contaminated downstream makes little sense. Thats why part of your water treatment strategy should include a plan for how you will prevent subsequent contamination.
Heating unit
RO unit
RO unit
90C
min 85C
Regular hot water ushing of the entire uid distribution system, including HD machines, can prevent bio lm.
Biolm prevention
Of particular concern is the development of bio lm in the system. Bio lms are communities of micro - organisms living under a protective slime matrix. They form readily in aqueous environments, release toxins that contaminate dialysis uid, and, once established, are virtually impossible to remove. Bio lms start when bacteria encounter a solid surface. They form a temporary bond to the surface and begin to multiply. Soon, they start developing a protective polysaccharide slime coat that forms a permanent bond with the surface.
Dialysis unit
Once the slime layer is in place, the microbes are, in all practical senses, impervious to both heat and chemical disinfection. The only proven way to keep bio lm out of your HD system is to prevent it from colonizing in the rst place. That means
eradicating all bacteria in the system before they have the time to develop a protective slime layer. A random schedule of disinfection is not sufcient; it should be performed on a regular basis without fail. Further, the entire uid path, all the way through the dialysis machines, needs to be dealt with.
Gambro has been developing water treatment systems tailored to the needs of HD clinics for over ten years. This CWP 100 by Gambro is available with either single- or double-reverse osmosis, has a built-in hot water tank, and is designed to perform daily unattended hot water ushing of the entire uid distribution system.
How choosing the right HD machines and concentrates can enhance uid purity
The next link in The Hygienic Chain is the HD machine. While most major brands of HD machines would appear to perform HD equally well, their hygienic performance can vary greatly. As a result, the machines themselves can be a signicant source of contamination. Design elements like long ow paths, dead ends, complicated valves and chamber systems all increase the risk of contamination. Thats because bacteria, yeast, fungus and other microbes thrive in still uid. Dead ends cause stagnant uid zones and are often difcult to reach with disinfectants. The same can be said of areas where the ow rate is low. Complicated valves allow microbes to hide and chamber systems can double as bacterial incubators between treatments. The use of liquid bicarbonate concentrates adds to this risk.
Many HD machines have complicated ow paths that favor microbial growth. Note the numerous valves, low ow areas, and holding tanks where uid can sit between treatments.
From their inception, Gambro HD machines have been designed to resist microbes and enhance uid purity. Note that Gambro machines can be drained and have no reservoirs where dialysis uid can sit between treatments.
Note the simplied ow path in the Gambro machine. This ensures an even ow rate throughout the entire uid path, giving microbes nowhere to hide during heat or chemical disinfection. Youll also note that the Gambro machine has no reservoirs where dialysis uid can sit between treatments. Microbe-friendly ow path design often results in bio lm inside the HD machine. If that happens, one
must rely on disinfection to kill the microbes or the dialysis membrane to keep contaminants away from the patients blood stream. Unfortunately, neither of these measures can provide adequate protetion. The slime which covers the microbes is extremely robust, able to withstand both heat and chemicals. Whats more, many of the bacterial byproducts released from the bio lm are clearly small enough to pass freely through any dialysis membrane.
BiCart enables easy safe and hygienic preparation of dialysis uid. Today BiCart is an essential part of both The Hygienic Chain concept and Gambros BiCart Select package that also includes SelectCart dry sodium chloride and SelectBag minor electrolytes.
The CleanCart concept provides easy, safe and effective disinfections and cleaning.
UF
A conc
RO
Ultralter 3 U 2000
Ultralter 1 U 8000 S
Ultralter 2 U 8000 S The ULTRA system by Gambro, with its set-up of ultralters, provides ultrapure dialysis uid and non-pyrogenic substitution uid for HDF or HF.
Preventative maintenance
The effectiveness of all other purity precautions is seriously reduced if the tubing is home to thriving communities of bacteria and other microorganisms that are found in biolm. Sometimes this lm can be observed with the naked eye as a creamy yellowish deposit coating the inner surfaces of uid pipes. Since these microorganisms are securely fasted to the walls of the tubing, they are not oating in the uid and therefore will not be revealed by CFU counts of the uid. Nonetheless, they serve as a reservoir of toxins that are constantly leached into the system. While bio lm is virtually impossible to remove, it can be prevented from establishing a presence. Prevention with daily prophylactic disinfection is the only known answer. That is, daily circulation of hot water through the entire uid circuit in your clinic. Its not difcult. In fact, the Gambro system can perform this daily routine automatically during non- dialysis periods.
Bio lm poses a real threat to tubing. Here the tubing has not beeen regularly ushed with hot water. Within two years bio lm is clearly evident.
Gambros automatic hot water ushing program stops bio lm before it starts. Here, Gambros prophylactic hot water ushing of the tubing results in a surface that is as clean two years later as the day it was installed.
Often overlooked, tubing can be the critical weak link in many hygienic chains. Gambros PEX tubing resists heat, is exible, tough, and chemically inert.
Tubing
The choice of tubing is important. There are many requirements placed on HD system tubing. It should be tough, exible, heat resistant, chemically inert, and have a smooth inner surface. Meeting all these requirements, our PEX tubing is ideally suited for the specialized demands of the HD clinic. Its tough yet easily bendable and can be installed in long sections without joints. This is important because joints favor the growth of bio lm. All in all, PEX tubing offers an advantage over any other type of tubing, including electro -polished stainless steel.
A nal word
Fluid purity is a topic of increasing importance in HD treatment. With this bro chure we hope to promote an approach we call The Hygienic Chain concept. Our aim is to demonstrate the importance of uid purity and explain how we achieve it. As part of that message, I would like to express Gambros dedication to The Hygienic Chain concept as a way to better serve you and your patients. The Hygienic Chain concept has been a guiding principle in Gambros product design for decades. It is reected in a string of Gambro innovations like hygienic uid path design in our HD machines, on-line heat disinfection, on-line preparation of bicarbonate from dry powder, and on-line preparation of HF/HDF infusion uid all Gambro rsts. It is also reected in our product range, which provides a complete hygienic chain solution. Gambro can provide every link in the hygienic chain from water treatment to ultra lters. If you are considering replacing your water treatment system, now is the time to make your clinics hygienic chain even stronger. I hope that the ideas presented in the booklet will help you and your patients with the highest quality dialysis treatment available. Sincerely,
Contact Gambro
If you are planning an update to an existing clinic, call Gambro to see how we can work with your current equipment to maximize uid quality and minimize the risk posed by bio lm. If you are planning a new HD clinic, we recommend that you consider establishing a fully integrated hygienic chain from the start. Your Gambro representative would be happy to consult with you.
Gambro Lundia AB International Marketing Box 10101, SE-220 10 Lund Sweden. Tel +46 46 16 90 00 Fax +46 46 16 96 97 www.gambro.com
HCEN1156 2003. 09. Rev. 2. Gambro Lundia AB. 2001 June. Printed by Elanders Skogs Graska AB.