Prebypass Checklist

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: ____________