Prebypass Checklist

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This is a sample pre-bypass perfusion checklist provided by AmSECT with additional input from Perfusion.com.

Sample Perfusion Checklist Updated 2018

This is a guideline, which Perfusionists are encouraged to modify to accommodate differences in circuit design and variations in institutional clinical practice.

Patient ID ______________________

Check each item when completed, sign and date. If not applicable, draw line through and leave a detailed comment.

PATIENT

  • Patient identity confirmed
  • Procedure confirmed
  • Blood type, antibodies confirmed
  • Allergies checked
  • Blood bank number confirmed
  • Medical record number confirmed
  • Chart reviewed
  • Participated in procedure “time out”

STERILITY/CLEANLINESS

  • Components checked for package integrity/expiration
  • Equipment clean
  • Heat exchanger(s) leak-tested

PUMP

  • Occlusion(s) set
  • Speed controls operational
  • Flow meter in correct direction and calibration
  • Flow rate indicator correct for patient and/or tubing size
  • Rollers rotate freely
  • Pump head rotation smooth and quiet
  • Holders secure
  • Servoregulated connections tested

ELECTRICAL

  • Power cord(s) connection(s) secure
  • Servoregulation connections secure
  • Batteries charged and operational

CARDIOPLEGIA

  • System debubbled and operational
  • System leak-free after pressurization
  • Solution(s) checked

GAS SUPPLY

  • Gas line(s) and filer connections secure
  • Gas exhaust unobstructed
  • Source and appropriate connections of gas(es) confirmed
  • Flow meter / gas blender operational
  • Hoses leak-free
  • Anesthetic gas scavenge line operational

COMPONENTS

  • System debubbled and operational
  • Connections / stopcocks / caps secure
  • Appropriate lines claimed / shunts closed
  • Tubing direction traced and correct
  • Patency of arterial line / cannula confirmed
  • No tubing kinks noted
  • One-way valve(s) in correct direction
  • Leak-free after pressurization

SAFETY MECHANISMS

  • Alarms operational, audible and engaged
  • Arterial filter / bubble trap debubbled
  • Cardiotomy / hardshell venous reservoir(s) vented
  • Vent line(s) tested with fluid
  • Venous line occluder(s) calibrated and tested
  • Devices securely attached to console

ASSISTED VENOUS RETURN

  • Cardiotomy positive-pressure relief valve present
  • Negative- pressure relief valve unobstructed
  • Vacuum regulator operational

MONITORING

  • Circuit / patient temperature probes placed
  • Pressure transducers / monitors calibrated and on proper scales
  • Inline sensors calibrated
  • Oxygen analyzer calibrated

ANTICOAGULATION

  • Heparin time and dose confirmed
  • Anticoagulation tested and reported

TEMPERATURE CONTROL

  • Water source(s)connected and operational
  • Temperature range(s) tested and operational
  • Water lines unobstructed

SUPPLIES

  • Tubing clamps available
  • Drugs available and properly labeled
  • Solutions available
  • Blood products available
  • Sampling syringes / laboratory tubes available
  • Anesthetic vaporizer correct
  • Vaporizer operational and filled

BACKUP

  • Hand cranks available
  • Duplicate circuit components / hardware available
  • Emergency lighting / flashlight available
  • Backup full oxygen tank with flow meter available
  • Ice available

EMERGENT RESTART OF BYPASS

  • Heparin time and dose confirmed
  • Components debubbled
  • Gas flow confirmed
  • Alarms reengaged
  • Water source(s) connected

TERMINATION CHECKLIST

  • Venous assist off / cardiotomy / venous reservoirs vented
  • Shunt(s) closed
  • Vent(s) clamped / removed

POSTBYPASS CHECKLIST

  • Announce bypass terminated
  • Arterial and venous lines clamped
  • Arterial circuit bubble-free before transfusing perfusate
  • Pump suction(s) off
  • Cell saver re-infusion bags de-aired and labeled

Comments:

Signature: _____________________________

Date: ________________ Time: ____________

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