It was reported that the return line of the prismaflex set became disconnected from the patient's dialysis catheter during continuous renal replacement therapy.
It was reported that the patient was recently repositioned with three people for the sole purpose of watching all lines and airways.
However, a disconnection was noticed 10 minutes after the repositioning.
The prismaflex control unit did not generate an alarm.
The return line was clamped and at this time, the machine generated an alarm.
The patient was treated with one unit of blood and it was reported that levophed "requirements were increased temporarily".
The patient outcome was not reported.
No additional information is available.
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