[HSF] Intimal Tears

[Prasanna Simha M]

I once had a trainee perfusionist  give noradrenaline  instead of Adenosine.
The company used to making the ampoule's had made the packaging similar and
also nearly similar sounding names.He had prepared the cardioplegia and was
running the pump undr supervision of a qualified perfusionist. He was a
pretty sharp boy and in hind sight the making of the cardioplegia and
laoding of syringes was not physically monitored.
Every time cardioplegia was given the BP shot up to MAP's of 150 and I was
wondering what was happening and I asked then to check the cardioplegia. The
boy himself diagnosed the problem and the cardioplegia was immediately
changed. Surprisingly the patient did extremely well (So much so that I
joked that maybe it couldbe added as a cardioplegia additive. I later talked
to the company and asked them to make distinctive packaging for the same
apart from making the perfusionists double anccross check every drug as a
part of the protocol. It was a lesson both the boy and myself did not
forget. He has become a very good perfusionist now.
Prasanna
On Feb 5, 2008 6:32 AM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> Hal
>
> Yes it was a resident who was not not appropriately supervised. We had all
> sorts given through the line - vasopressin, norepinephrine, propofol - for
> several hours before recognized. Complication was ultimately fatal.
>
> Ani
>
>
>
>


-- 
Prasanna Simha M