AmSECT Perfusion Checklist

AMERICAN SOCIETY OF EXTRACORPOREAL TECHNOLOGY


	AmSECT PERFUSION CHECKLIST ______________________ Patient ID Check each item when completed, sign and date. If not applicable, ~~draw line through.~~ *Bold italicized items for expedited set-up.* PATIENT *Patient identity confirmed* *Procedure confirmed* *Blood type, antibodies confirmed* *Allergies checked* Blood bank number confirmed Medical record number confirmed Chart reviewed 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 lead-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(s) tested* 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) clamed / removed* POSTBYPASS CHECKLIST *Announce bypass terminated* *Arterial and venous lines clamped* *Arterial circuit bubble-free before transfusing perfusate* Pump suction(s) off Comments: Signature: _____________________________ Date: ________________ Time: ____________ These perfusion checklists, or a reasonable equivalent, should be used in perfusion practice. This is a guideline, which Perfusionists are encouraged to modify to accommodate difference in circuit design and variations in institutional clinical practice. Users should refer to manufacturers’ information, including Instructions for Use, for specific procedures and/or precautions. AmSECT disclaims any and all liability and responsibility for injury and damages resulting from following this suggested checklist. Origination 1990; revision 2004 by AmSECT Quality Committee.	FOR MEETING INFORMATION AmSECT National Headquarters 2209 Dickens Road Richmond, VA 23230-2005 Phone: (804) 565-6363 Fax: (804) 282-0090