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) 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: ____________

Source