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 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(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) clamped / 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.