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Friday, March 15, 2013

Troubleshooting the Moog/Zevex Enteralite Infinity Pump

The day I brought Raya home from the hospital with her first feeding tube was the first time I ever saw a portable feeding pump in person. I didn't get a manual with the Kangaroo Joey pump that was dropped off to Raya's hospital room by the home health rep and I got a 5 minute crash course on how to use it. Fast forward 5 months and I had a 7 month old who was not yet crawling but was too mobile for the Joey pump. I called up our home health provider and told them that we couldn't take another day with the Joey, and the next day they swapped it out for a little bitty Zevex Enteralite Infinity (now it's Moog, not Zevex). Again, no manual.

The pump is not difficult to operate, but without a manual, there's just no way on earth to figure out how to do certain things with it or even realize that certain features exist. I spent a lot of time jiggling things, pulling on tubing, resisting the temptation to throw it at the wall, and holding down the PRIME button on the pump in hopes that it would make the pump stop beeping. Moog has removed the manual from their website, presumably to give it an overhaul and replace all the Zevexes with Moogs, but fortunately it's still available on other websites. I saved it to my hard drive just in case it disappears from those too. Moog does still have a handy little troubleshooting guide on the website, but it's definitely not the same as the full manual. And manuals are boring to read, so I thought I'd share some of what the manual says only with actual pictures instead of drawings, and in my own words, which (IMO) are much more fun than the manual. (I used to have a link to the manual here but those links go bad often so just google Zevex Infinity Pump Manual and you'll probably find one that works.)

Without further ado, here is a little bit of information about the different alarms on the Moog Enteralite Infinity pump:


Self-test failure alarms: They can be ERRA-ERRZ or can have ERR followed by numbers, like ERR 63, and a continuous beep that makes you want to throw it against the wall. We've had pumps that would do that once or twice a month and it's one of the most irritating alarms because it would reset all of the pump settings to 0 and clear out all of the volume information. All you can do about those is turn it off and turn it back on. If the alarm continues to go off after you've turned the pump off & back on, then the pump may have some kind of internal failure and will need to be replaced or serviced by the home health provider, so call them ASAP.

Load set: This alarm will bark at you if you happen to push the run/pause button without a pump set loaded in the pump.

Low Battery: The manual says that this alarm will go off when there's less than 1 hour of battery life left. In our 2 years and 9 months of experience with the Infinity pump, we've NEVER had one last more than 15 minutes once the low battery warning goes off. Most of them have turned off within 5 minutes of the first low battery warning. Never leave home without having the pump charged. :)

Push Run to Feed: This alarm is kind of insulting. It might as well be saying, "Hey slowpoke, can't you do meds and refill that bag in less than 2 minutes?!" Or, "Hey! You forgot to start the feed!" But yeah, all you have to do is push the run button to stop the alarm and then push it again to start the feed. I've learned though, that if you know the alarm is about to go off, all you have to do is push any other button on the pump and it won't beep for another 2 minutes.

Dose Done: This one isn't so bad because you can turn it off. I was so happy when I found that out! Here's how you do it:
Turn pump off. Push + and on/off at the same time and hold them down until the pump comes on (about 2 seconds). The pump will display options for different settings, and to change them, you push the + or - key. When you're done with the first setting, push the Prime button and then repeat the process with the other settings. You can change the volume of the pump alarm, lock & unlock the buttons (it only prevents changing feed settings & doesn't actually lock all the buttons), end of dose alarm, and the display light on or off.

Check: This alarm will go off if you push Run and the current interval setting is not compatible with the dose and/or rate. For example, if you have the pump programmed to feed a dose of 200ml every 3.5 hours but you only have the rate set at 50ml per hour, the pump can't deliver the whole dose because it would take 4 hours to deliver the entire dose. If you get this alarm, make sure you actually meant to have the interval setting programmed and that it's programmed correctly with the dose & rate. (Interval is the INT button.)

Shut Door: This one isn't actually listed in the manual, or at least not in the section about alarms. We discovered that this one existed when Raya was supposed to be napping but threw the pump on the floor instead. I walked in and the pump door was laying a couple feet away from the pump. The screen was flashing, "Shut Door" over and over again as if it was crying out for someone to help it. On a side note, if the door ever cracks or the latch breaks and won't stay shut, you can call Moog and get a replacement door so you don't have to hold it on with a rubber band. (been there, done that)

Ok, so those are the more boring pump alarms. The enemies of every tubie & tubie parent are the NO FLOW IN, NO FLOW OUT, and NO FOOD alarms. These are the ones that make our blood pressure rise, rob us of our sleep, and make us want to throw the pump at the wall. Am I right??

When my Feeding Tube Awareness colleague, Traci, and I met with the representatives from Moog last month, they gave us a little Enteralite Infinity anatomy lesson. It wasn't anything earth-shattering, but it did shed some light on things that I hadn't really paid attention to before. It had never occurred to me (or I had never bothered to care) that each of the "big 3" alarms has its own sensor. As soon as they said that, it of course made perfect sense, it just wasn't something I'd thought about before. Here's how it works:

And here are the corresponding areas on the pump set:
The IN & OUT areas are soft, squishy tubing that runs through sensors that can tell if there is too much pressure in that small segment of tubing, which would mean that there's a blockage somewhere. The FOOD area is hard plastic that's almost triangular in shape. We'll get to that again later. First, the No Flow In alarm. (I don't like it in all caps. I think that's why I always feel like the machine is yelling at me.)

No Flow In:
A No Flow In alarm means that there is an obstruction somewhere between the pump bag and the pump, so that's where to look. This can be caused by a number of things. One cause, especially when powdered formula is involved, is clumping of formula. This is why it's important to mix formula thoroughly and allow foam to settle before pouring it into the pump bag. (Here's a blog post all about mixing formula.)

Here are a couple of other things that commonly cause No Flow In alarms:
Before Moog took over as the manufacturer of pump bags, the bottom of the bag was different than it currently is. I had forgotten exactly what it looked like until I found one or two of the old ones buried in a bench full of medical stuff. The new bag design has a hard plastic piece (official title: "no-roll flange") at the bottom to keep the bottom of the bag from folding over and blocking formula from leaving the bag. Sometimes though, when the pump bag is in a backpack, the hard plastic piece can get pressed against the back of the bag and block the flow of formula, which results in a No Flow In alarm. The other common cause that we see is when the tubing gets a kink in it right where it's leaving the bag. This is usually either a result of the pump bag laying funny inside the backpack (especially in backpacks that don't have straps & hooks to hold everything in place) OR it's because the tubing was smashed funny in the manufacturer's packaging and is perma-kinked. If you have a bag where the tubing is perma-kinked (meaning you can't make the tubing stop kinking) you might as well throw it out and get a new one because it's going to keep beeping at you. You CAN try wrapping several layers of tape around the kinked area to keep it straight but if it doesn't work, just get out a new one.

This is our other most common cause of a No Flow In alarm:
This happens when the bag runs out of formula and we've done a good job getting all the air out of the bag. When that happens, we just refill it and send her off on her way.

This next picture shows a common cause of both No Flow In and No Flow Out alarms:
This happens most often for us when the pump is in the backpack. Usually we just have to readjust the pump bag if it's a NFI alarm or make sure there's enough slack in the exit tubing if it's a NFO alarm.

No Flow Out:

The evil stepsister of the No Flow In alarm. No Flow Out alarms happen when there's an obstruction between the pump and the person. I don't know if it's even possible to list all of the things that can cause a No Flow Out alarm but I'll try. For us, it's most often a kink in the pump tubing. Like this:
That's what happens when I let Raya carry her backpack instead of wearing it. It also happens sometimes when the tubing that's coiled up inside her backpack gets smashed & kinks. A little rearranging usually does the trick.

Another common cause of NFO alarms for us is when she's wearing the backpack and the tubing starts to fall out of it and makes the extension tube kink. OH, and how could I forget Raya's preschool teacher's FAVORITE cause of the NFO alarm: Mommy forgot to unclamp the extension tube at drop-off! It's happened a couple of times. Once I remembered as I was pulling out of the parking lot that I most definitely had not unclamped the tube when I pushed the run button as I was dropping her off. I felt bad but they figured it out. Lately she has learned how to clamp the tube herself, so that's been the cause of some of our No Flow Out alarms recently.

For kids with really poor gastric motility (or intestinal motility if J fed), sometimes the pressure from their stomach or intestine can cause the No Flow Out alarm to go off. If you ever suspect that that's the case, call the doctor ASAP.

Lumpy formula can also cause No Flow Out alarms, and so can clogged feeding tubes (NG, NJ, G, GJ, J, etc.) and clogged extension tubes. If you can't immediately tell what's causing it, the best way to deal with a No Flow Out alarm is to pause the feed, hold down the Prime button for a few seconds, and then push the run button again. If there's something inside that little portion of tubing inside the cover (see earlier photo), or if there's a little lump of something blocking the feeding tube, holding down the Prime button for a few seconds can clear it out and make things run smoothly again.

No Food Alarm:
Out of all the pump alarms, this one can absolutely be the most frustrating. One of the biggest complaints we hear on the Feeding Tube Awareness facebook page about the Infinity pump is the phantom No Food alarms. The pump manual says, "It takes approximately 1ml of air, which is approximately 5 inches (12.7cm) in length entering the teal colored tubing to cause an alarm." I actually laughed out loud when I read that. It takes a whole lot less than 5 inches of air to cause a No Food alarm. Heck most of the time there's NO air and it still alarms No Food!

There are a lot of things that can cause no food alarms, and most of them don't actually involve a lack of formula in the pump. For parents of young children, especially mobile babies & toddlers, the ability to remove all air from the pump bag and have it turned every which way is the most appealing thing about the Infinity pump. That's what sold me on it. However, if you don't get ALL the air out and the bag happens to get turned upside down, even small air bubbles can cause a No Food alarm. If it's just a tiny bubble, I usually just prime it past the sensor and let it go. However, when we were doing jejunal feeds and when Raya's stomach was a lot more sensitive (or when it's a larger bubble), I disconnect the pump tubing from the extension and prime the air out of the tubing so it doesn't end up in her body. Foamy formula can also cause a No Food alarm. And that's pretty much all there is to legit No Food alarms.

Phantom No Food alarms can be caused by several things, with one of those being dirt or cracks in the clear plastic inside the pump cover.
If you're getting a lot of No Food alarms for no reason, clean the sensor with a wet Q-tip. Don't rub it with anything harsh (like a washcloth) that could potentially scratch the plastic over the sensor because that will make the problem worse. You can clean the pump by running it under water as well. (make sure it's not on when you do it...) The manufacturer says it's okay to use a mild soapy water solution and a "nonabrasive sponge or soft cloth" to wipe any gunk off. We've had to do this several times in the recent past thanks to the pump bags spontaneously breaking and bathing the entire pump, inside and out, in formula. Which brings me to the next point: it may also be necessary to clean the part of the tubing that goes in front of the sensor:
Another very frustrating cause of No Food alarms is switching from formula to Pedialyte or water and using the same bag. For whatever reason, when a bag has been used for formula and then is used for clear liquid, the pump has trouble "seeing" the liquid. This problem can be avoided by adding just enough formula to the Pedialyte to make it cloudy. Some pumps are more sensitive than others and have difficulty even running Pedialyte out of a fresh bag. Adding food coloring to clear liquids can help prevent phantom No Food alarms. If all else fails, there's one other thing that can be done to prevent a No Food alarm, but it comes with a very strong caution.
I would not do this until I had first tried a new pump bag, tried food coloring, and added formula to make the clear liquid cloudy. If none of those things stop the phantom No Food alarm, you can use a marker to color in the hard plastic that goes over the No Food sensor in the pump. The risk here is that the pump WILL NOT be able to read a legitimate No Food situation, so if the pump bag has air in it and runs out of liquid, it WILL pump air into the person. That can be painful and dangerous, so if, as a last resort, you do ever have to do this, be sure to remove all the air from the bag and use a dose setting, not the INF setting on the pump.

Ultimately, for any of these 3 alarms, if none of the things you do make the alarm stop going off, get out a new pump bag. If you have the same problem with multiple bags from the same lot number, try using a bag from a different batch. Sometimes the batch has a problem (sorry, Moog, but it's true) and the only way to stop having the same problem over and over is to use bags from a different batch. If that doesn't help, there might be something wrong with the pump & it might need to be exchanged with your home health company. No matter how badly you'd like to throw it at the wall, that doesn't usually fix pump alarms.

I'm sure I've left things out but I'll probably add to this later when I read back through it. Hopefully someone will find it helpful!

6 comments:

  1. This is a wonderful, very educational blog post!!! It's perfect for new consumers! Might even save them from pulling their hair out in the middle of the night while trying to deal with these stupid alarms! Love it! Definitely passing this on :) thanks!

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  2. This is a fantastic post! Thank you so much for sharing.

    ADDENDUM: Moog has now said there can be malfunctions when using the INF setting. (It can act like it is working and feeding, but it is NOT.) So for "sensitive individuals" (aka, those who cannot tolerate missing a feed for medical reasons), do not ever use the INF setting. Set the Dose to 3000 or some high number instead.

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  3. Great post!! Love the sensor info and pics!!

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  4. does anyone know what error code 13 is?

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    Replies
    1. That means there is some kind of internal error with the pump. If turning it off and turning it back on doesn't stop the error code, then you will have to call your supply company and exchange the pump. If you own the pump and your DME won't service it for you, you'll need to call the manufacturer about getting it serviced.

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  5. I love this post so much. The Infinity pump is my favorite and the longest lasting, most problem free one that we've had. But it's uncanny how often when I am so tired I can hardly think the dang thing gets the NO FLOW IN error. Usually after I unkink the tubing coming out of the bag I turn the bag around the opposite way on the hook so that it's pulling toward the pump in a different direction and that does the trick.

    Usually our NO FLOW OUT errors occurs when our son stuffs the tubing into his diaper and kinks it, probably to reduce the feeling that the tube is pulling on his button. When this happens he tends to do that a couple times a night for several days. I get awfully crabby getting up out of bed after the first time, but he's such a sweetie that I get over it quickly.

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