There was an interruption to IABP counter pulsation therapy out of hours. On arrival, alarm message was displayed "failure to pump". The gas line was inspected with no obstruction. Several attempts at re-institution of therapy were made unsuccessfully. A change of console was carried out and therapy was recommenced.
Interruption to counter pulsation with IABP in standby for approximately 50 minutes.
Getinge Cardiosave Hybrid
On arrival of the on-call Clinical Perfusion Scientist, the console was changed out and therapy was recommenced. It was not deemed appropriate/necessary to change IAB catheter.
The affected console was taken out of service and repaired. It was noted post service that it was a failure of the safety disk.
Upon reflection what do you think went well?
The on-call Clinical Perfusion Scientist arrived promptly (approx 30 mins out of hours) and the console was changed out quickly with no issues.
New action plans/changes as a result of the event?
A teaching session with senior intensive care nursing staff (zone leaders) on troubleshooting and demystifying the IABP console to be arranged.
Troubleshooting flow charts have been added to the consoles to try minimise any downtime in patient therapy, should interruption occur. It is intended to have annual refreshers for this group of staff.
MHRA Informed