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: ____________




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