PERFUSION REPORTS

REPORT
036
DATE
1/10/2017
TITLE
Oxygenator issue
DETAILS OF INCIDENT

On initiation of bypass using a centrifugal pump, full calculated flow was achieved with RPM close to maximum (3500RPM). After 10mins of bypass, maximum RPM failed to achieve full calculated flow and steady decline of flow was observed for 39mins. The nadir flow during this stage was 4L/min. During this period, arterial line (post membrane) pressures reduced as flow reduced. After the nadir flow was reached, flow began to increase with maximal RPM. After this period of 39 mins until the end of bypass (another 82mins), RPM was decreased and >calculated flow was achieved. Prior to weaning from bypass RPM were at 3150 with a flow of 6l/min. During the bypass arterial line pressures (post membrane) correlated with flow. Pre-membrane pressures were not recorded. All of the patient's parameters were maintained within desired thresholds (arterial blood gas values, venous saturations, mean arterial pressure, ACT>400, DO2) throughout bypass. The supplier was informed but the device not returned.

DETAILS OF INJURY TO PATIENT

None. The patient was uneventfully extubated and returned to the ward before returning home.

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

N/A

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
REPORT NO
092
1/10/21
Vapourizer Issue
REPORT NO
091
1/10/21
Oyxgenator Leak
REPORT NO
090
1/10/21
Breach of chemical cleaner
REPORT NO
089
1/9/21
Sechrist Gas Blender Sweep on ECMO
REPORT NO
088
1/9/21
Oxygenator High Pressure Events
REPORT NO
087
1/10/21
Leaking one way valve
REPORT NO
086
1/7/21
Electronic Gas Blender Fault
REPORT NO
085
1/2/21
Protamine Administration Issue
REPORT NO
084
1/6/21
Damaged roller pump lid
REPORT NO
083
1/6/21
IABP malfunction
REPORT NO
082
1/1/21
Accidental cardioplegia administration
REPORT NO
081
1/4/21
S5 Double Roller Pump incident
REPORT NO
080
1/5/21
Human factors issue
REPORT NO
079
1/6/21
Centrimag battery module failure
REPORT NO
078
1/6/21
Sampling manifold valve fault
REPORT NO
077
1/5/21
IABP transport issue
REPORT NO
076
1/4/21
Modified Ultrafiltration (MUF) Issue
REPORT NO
075
1/3/21
Electromagnetic interference with HLM
REPORT NO
074
1/2/21
HCU40 Failure
REPORT NO
073
1/2/21
HCU40 valve failures
REPORT NO
072
1/1/21
HCU40 failure
REPORT NO
071
1/1/21
LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD
REPORT NO
070
1/1/21
Loose component on circuit
REPORT NO
069
1/12/20
Centrifugal Head noise
REPORT NO
068
1/11/20
Venous Reservoir disposable issue
REPORT NO
067
1/11/20
Failure of Heater Cooler due to leaking valves
REPORT NO
066
1/11/20
Failure of Valves on heater cooler unit
REPORT NO
065
1/9/20
Intra Aortic Balloon Pump (IABP) Failure
REPORT NO
064
1/9/20
Centrifugal head failure
REPORT NO
063
1/8/20
Centrifugal head issue 4
Perfusion Report cards are shown in batches of 30 at any one time where available.
123
122
121
120
119
118
117
116
115
114
112
111
110
109
108
107
106
105
104
103
102
101
100
099
098
097
096
095
094
093
092
091
090
089
088
087
086
085
084
083
082
081
080
079
078
077
076
075
074
073
072
071
070
069
068
067
066
065
064
063
062
061
060
059
058
057
056
055
054
053
052
051
050
049
048
047
046
045
044
043
042
041
040
039
038
037
036
035
034
033
032
031
030
029
028
027
026
025
024
023
London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.