PERFUSION REPORTS

REPORT

064

DATE

1/9/2020

TITLE

Centrifugal head failure

DETAILS OF INCIDENT

This event took place once the patient was cannulated and before CPB was initiated.

All pre-cardiopulmonary bypass checks were completed with no issues.

The centrifugal head was making a loud vibration when any RPM above 1200 was applied to the head. The head was re-seated 3 times to rule out a bad contact but each time the vibration and noise returned above 1200RPM. At which point the pump itself was generating heat and deemed to be a bearing failure. The decision was made to replace the faulty centrifugal head. Once completed no further issues were noted and the perfusionist commenced CPB.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Liva Nova Revolution Centrifugal head

ACTION TAKEN

Centrifugal head change out as per emergency protocol. No further issues or heat detected and CPB commenced.

Contacted manufacturer, MHRA, MDSO and internal critical incident form completed.

RESPONSE FROM MANUFACTURER

Awaiting response.

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

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