Description of Event or Problem · 1
PATIENT PLACED ON TABLE IN CATH LAB AND GIVEN I.V. SEDATION. ROOM WAS SET UP TO DELIVER SALINE AND CONTRAST SOLUTION AND MONITOR ARTERIAL BLOOD PRESSURE THROUGH A MERIT MEDICAL MANIFOLD. 500ML BAG OF SALINE WAS ATTACHED TO MANIFOLD, 150 ML BAG OF CONTRAST AND A PRESSURE TRANSDUCER, CATHETER WAS INSERTED IN RIGHT HEART AND 5 IMAGES WERE TAKEN. CATHETER REMOVED AND INSERTED INTO LEFT HEART WHERE 2 IMAGES WERE TAKEN. AT THIS POINT PATIENT LOST ALL ARTERIAL PRESSURE AND SA02 WAS DROPPING RAPIDLY. NO PULSE COULD BE FOUND. CPR WAS PERFORMED AND PATIENT WAS SUCCESSFULLY RESUSCITATED. IT WAS NOTED THAT THE SALINE AND CONTRAST BAGS WERE EMPTY AND THAT AIR WAS IN THE TUBING. PATIENT WAS TRANSPORTED TO THE C.C.U. WHERE HE DIED AND ALL RESUSCITATION ATTEMPTS WERE UNSUCCESSFUL.