[HSF] Intimal Tears

[Ben Bidstrup]

This is an important issue esp with regard to visual appreciation of 
data. (see Tufte ).

Do we have distinctively labelled ampoules for each drug and rely on 
the colour/shape and position to identify the drug or do we have them 
all the same and force a look at the writing on the label. After all 
this is the process for blood transfusion.

I saw protamine which was in a similar coloured ampoule to heparin 
given at the beginning of a case. Blood for flushing the vein clotted 
in the bowl as the arterial cannula was going in. The OR Nurse (my 
wife) stopped us from going further - until we were sure.

Great example also of cockpit resource management (see articles by 
Healy and others). BTW that happened nearly 25 years ago! Before CRM 
was really fully developed.

>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
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon