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MAY
22

Podcast 99 - We Tested the Sapphire IV Pump!

Screen-Shot-2020-05-22-at-7.53.09-PM

“Tube’s in.”

“Let’s double check that depth.”

“I’ve got a good end tidal CO2 waveform.”

“Saturations maintaining?”

“Tube still looks good in the glottis.”

"Let’s secure this thing." 

“How long ago did we give that ketamine?”

….

For some, the next words that that come out of someone's mouth may be a cause for trepidation: 

“Let’s start an infusion.” 

 

Med math starts rolling through your head. You start rummaging through your phone for a that grainy Facebook screenshot someone sent you a while ago of how to set up a ketamine infusion. ‘I remember it was super simple…’ 

Infusions give many clinicians a cause for anxiety. That anxiety might stem from poorly explained med math in school or training, memories of the IV pump not cooperating when you really need it to, and alarms - so many alarms. These problems have caused many to just go with push-dose medications to avoid using an IV pump completely - usually because it seems too cumbersome, and the task of learning how to use this piece of equipment well can seem daunting. FOAMfrat has always believed that infusions can be started quickly, and lead to better patient care. Infusions let you avoid the peaks and valleys of push-dose medication. Infusions also reduce your cognitive load - having to remember to push a medication at timed intervals can easily be forgotten when you’re dealing with multiple issues at once. The last thing anyone wants to do is forget to administer that anesthesia when your patient is paralyzed. For these reasons, and because the industry is currently looking into IV pump solutions, we were happy when QCORE Medical asked us to review the Sapphire IV pump. How did it go? 

 

 

Accuracy Testing

Accuracy has been a topic of conversation in the industry in light of recent events. So, the first thing we wanted to do was evaluate if the Sapphire pump was actually putting out the amount of volume it says it is. 

Methods: LR was used as the fluid. We ensured that the weight of 1mL of LR was 1 gram, and then used that weight to determine how much fluid the pump infused at the end of the test. Graduated cylinders were used to measure fluid, and a scale that measures in whole grams was used to track weight (two confirmation methods). 

We designed three different infusion tests: 

 

1. 250mL at a rate of 999mL/hour.

2. 100mL at a rate of 600mL/hour.

3. 37mL at a rate of 37mL/hour (with three different fluid height variables). 

 

The pump performed very well. Even when the pump was slightly off, it was well within acceptable range. A couple important things to note:

  1. QCORE has performed the 250mL bolus at 999mL/h as well, and they came up with a max 3.5% discrepancy (obviously within acceptable range). Their equipment for testing is much more advanced than mine, as are their methods. I would trust their measurements much more than ours. Our methods for testing these pumps are very elementary.
  2. For the 37mL infusion at 37mL/hour, the lower levels of fluid height were meant to produce an error. For the this type of pump to perform at peak accuracy, your should always have your fluids above the pump - this is the way it’s designed to work. So, having a very small error when the bag is far below the pump for an hour is to be expected. 

 

 

Battery Life Testing

These tests were very simple. We programmed the pump to be on a continuous infusion by plugging a half-set into itself. Then, we programmed the rate to 750mL/h and the volume to be infused to the max (9,999mL). While 750mL/h is a little arbitrary, we though this would put the pump under some stress since this is a pretty high rate. Cold temperatures also impact battery life, so we wanted to test that out as well. 

The test was basically an endurance test. We set the pumps to run continuously, and then waited for the battery to deplete completely. The pump does alert you when it believes you have 30 minutes of battery life left, and we found this to be very accurate. The room temperature pump (70º f) went for ~16 hours, while the pump we placed in a fridge (30º f) went for ~11 hours.  

 

 

Screen Testing

Since the pump that was placed in a fridge has plenty of time to get cold, we wanted to see if this would impact the screen performance as well. Cold temperates did not impact screen function as you can see from the vodcast. People also asked if direct sunlight would cause the pump to error, and the answer is that we did not see any alteration in function while the pump is in direct sunlight. The question about sunlight likely stems from another pump people are familiar with having errors for some reason when exposed to sunlight - this does not seem to be the case here. 

Another aspect of the screen performance we tested was what happens if the screen is wet, or you have fluid on your gloves? This screen is not like the screen on your smart phone - those have issues when water contacts the screen causing you to have issues in selecting the correct area of the screen. The screen on the Sapphire is pressure sensitive only, so moisture on the screen does not change its performance. We poured water all over the screen, and we were still able to program in settings with no issue. 

 

 

 

 

Ease of Use Testing

How easy a pump is to use is really where the rubber hits the road. In the outset we noted that people have reservations about using IV pumps because of the perceived difficulty of use (this includes how difficult a cassette is to place into the pump). 

Cassette

This is our favorite cassette we've used. The first thing I noticed is that the cassette has tubing that runs straight through it, which makes it really easy to get air bubbles out. You don’t have to turn it every which way, squeeze it, and inspect it to no end to ensure your line is clear - it primes just like any non-pump tubing you’ve ever used. The other aspect of the cassette is that you could place it with a blindfold on. My neighbor (no medical experience) came over while we were testing this device and we asked him to place the cassette into the pump however he thought it worked. He immediately lined it up and clipped it in with no issues. Check out the Vodcast to see us placing it multiple times without the need to troubleshoot it. It only occurred to us after the testing was totally complete that we never had any errors or problems with the cassettes at all. Kind of like the battery life, we found ourselves not even thinking about it. 

User Interface

The last thing you want from user interface is the equivalent of ’10 codes’ where you need to study and memorize them in order to use them correctly. There is a reason we have all gone to using plain speech - there is much less miscommunication. That is how you want a user interface - plain text that tells you exactly what you’re doing. There are basically 2 options when it comes to starting an infusion that the user interface makes plain how to use. 

  1. Start from scratch. You can choose to manually type in a bolus by typing in a volume and time, or you can type in a drug dose by using its concentration and desired dose. These are pretty quick to set up. From powering on the pump to getting a bolus going, it took us just under 50 seconds. To type in a drug from scratch (mcg/kg/min) it took exactly 1 minute. Not bad. However, you can cut these times down even further by using the drug library. Something that we didn't do in the video but is very useful is programming in only the amount of drug on hand and the amoutn of fluid. This will program your concentration automatically, which pretty much eliminates all need for medication math (although you should always have a method to double check your work). 
  2. Use the drug library. You can program in any medications you want to use and the pump will keep it inside of its drug library (DL). You can search by name, or just hit “find” and scroll through a list. The drug library allows you to store the concentration, so that all you have to do is type in how much volume you have on hand, and what dose you want to run at (and kilograms if weight based). This is by far the quickest method of starting an infusing.

Either way you go, even with limited training, a clinician can likely count on the whole IV pump part of the process taking ~1 minute. This includes turning the pump on, placing the cassette, and programming it. We did not include spiking the bag and priming the tubing into this time because that is all pretty universal to any IV pump - we wanted to isolate THIS pump as the variable. 

 

 

 

Drop Testing

This was stressful because even though QCORE Medical told us it was totally fine to drop the pumps, we had become a little attached to these pumps and didn’t want to break them. We felt like we just took an iPhone out of the box and now were going to throw it on the floor. The pumps are rated to drop from 1 meter, so that’s what we did as well. What happened? The pumps were denting the floor before the pumps were showing any signs of problems. Would things have been different if we were dropping them on concrete? Perhaps, but we think the hardwood floor in the living room is a fair test as well. We dropped a pump almost 15 times (the last 6 recoded and put in the vodcast), and it never stopped pumping or gave us any alarms. Sometimes the door over the cassette would pop open, but this doesn’t stop the pump from infusing. They seemed to handle the abuse well. It’s a good start to being considered ‘EMS proof’ and these pumps to feel very sturdy. 

 

What did we really think of the Sapphire IV Pump? 

Prior to receiving the pump, we had reservations about the Sapphire. Why? Mostly because of the fact that it is a single channel IV pump. With other pumps on the market that have two or three channels, could that convenience be compensated for by user experience? We believe the answer is yes. Not only is this pump accurate, but it’s durable and easy to use as well. This is a ‘no explanation needed’ kind of product. In our opinion, the user interface is really the selling point of this pump. The touch screen and plain text leave nothing to guess-work. If you need an option, it’s right in font of your face and available for use. Not to mention… rumor has it that there may be a three pump holder coming out in the very near future (see picture below). 

“Let’s start an infusion” doesn’t have to be such a scary phrase. If we can get people confident in their ability to start an infusion and trust that their equipment won’t fail them, we can deliver better patient care- and we beleive the Sapphire IV Pump is a great step in getting there. 

 

 

 

0
DEC
08

Microgram - Is Flow Additive?

I posed the above poll on Twitter to see what people thought. The reservoir answer, while the most popular, was actually a distractor item - that option doesn't actually have anything to do with liter flow / speed. The basic question here is: If you add more devices to a patient, does it increase the overall speed of oxygen deliver? Why does this even matter? 

If a patient has an inspirtory flow demand that exceeds the flow of gas we are delivering to them, they will entrain room air in inhalation, causing the fraction of oxygen we are delivering to them to be diluted. Therefore, we want to do our best to meet or exceed their inspiratory flow demands. I know a lot of people are using flush with these devices, but I wanted to use the standard 15 Lpm in this example to drive the point home. 

 

Check out this illustration:

You have 30 gallons per minute hitting the bottom of the tank. Behind the mystery door, would you be able to tell me how many hoses are feeding that 30 gallons per minute flow? No. I could have 10 hoses running at 3 gallons per minute, or 2 hoses running at 15 gallons per minute. What really matters is the total amount of volume that is hitting the bottom of the tank over a set time limit (in this case one minute). 

One hose is running at 5 gallons per minute, another at 15, another at 10. We can see that none of these hoses are running at 30 gallons per minute, but their combined flow does cause 30 gallons per minute to be delivered to the tank. The hole in the tank (representing our patient taking in air) is irrelevent to the speed coming in - though it does have other clinical implications. Our goal would be to create a reservoir for the patient. What would that look like in our illustration? The tank filling up faster than it is draining - this would be exceeding the inspiratory demands of gas flow. 

 

Another illustration: 

You may think, but if you're looking at two cars driving down the road at 15 MPH that there speed is not additive. In this instance, you would be correct. However, we have to look at this problem differently to get the answer we are looking for. 

 The amount of cars delivered to the pile is an accurate representation of the amount of volume delivered, not how many MPH it is traveling on the road. 

 In conclusion, yes, the flow we are delivering with two devices is additive. This is important information when we consider strategies to rid the patient of nitrogen, do our best to meet or exceed their inspiratory demand, and reduce anatomical dead space. 

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