It was reported that during continuous renal replacement therapy (crrt) treatment with a prismaflex hf1000 set, there was a crack noted the at syringe tubing close to the syringe resulting in a heparin leak.It was reported that approximately 48 hours after initiation of crrt, the heparin syringe was exchanged, after which there was consistent activated clotting time issues, frequent heparin bolus, and increase in heparin infusion rate.One day later, it was observed that "liquid found on syringe arm of prismaflex¿ was coming from a crack at the heparin syringe tubing close to the syringe (green pressure backflow valve) causing the heparin leak.The prismaflex hf1000 set was changed, and blood was not returned to the patient due to high hemoglobin.The treatment was restarted using a new circuit.Seven days later, the patient was taken off dialysis for approximately one and a half hours (reason unknown).It was reported that seven minutes after the new treatment started, the patient became hypotensive and treatment was stopped.Treatment was again restarted approximately two hours later.On the same day, the patient was reported to be fibril and septic (exact times not reported) with acute decompensation during the cause of the day and eventually passed away.The cause of death was not reported.It was not reported if an autopsy was performed.No additional information is available.
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