It was reported that a pediatric patient became hypotensive and experienced tachycardia approximately two hours after starting continuous renal replacement therapy using a prismaflex control unit and a prismaflex m60 filter.The patient was treated with a fluid bolus and one dose of calcium.The patient's condition was reported to have stabilized.On the same day, reported as later in the evening, a check return alarm, immediately followed by a return disconnection alarm and then immediately followed by an air in blood alarm was generated by the prismaflex control unit.No disconnection or air in the return line was observed.The air in blood alarm could not be cleared and the nurse was unable to hit stop during the air in blood alarm.The machine was turned off and the blood was not returned.The amount of blood loss was not reported.The patient was re-connected to a new prismaflex control unit and a new prismaflex m60.Thirty minutes later, the patient experienced bronchospasm, hypotension and tachycardia in the 160s.The pre blood pump prescription was increased and the patient was given a fluid bolus and two doses of calcium.The patient's condition stabilized.Shortly afterwards, "the patient was at full flows on the circuit per prescription" and the patient began to show clinical signs of change.Approximately twenty minutes later, the machine alarmed with return disconnection and filter clotting.At this time, the patient started seizing, experienced bradycardia, and became hypotensive.At this time, the patient's pupils were observed to be fixed and no pulse was palpable.Treatment was terminated and blood was not returned to the patient.Amount of blood loss was not reported.Cardiopulmonary resuscitation was performed for 45 minutes before the patient stabilized and was placed on extracorporeal membrane oxygenation.No additional information is available.
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