PERFUSION REPORTS

REPORT

076

DATE

1/4/2021

TITLE

Modified Ultrafiltration (MUF) Issue

DETAILS OF INCIDENT

At the end of the bypass run, MUF was initiated.

After a short time air was seen in the oxygenator. MUF was discontinued.

It was found that the orientiation of the oxygenator outlet was causing the arterial link to kink. This was then causing cavitation within the oxygentator as the MUF was not able to draw blood from the patient. The circuit was re-primed and incidentally a further run of bypass was required.

Following this run, 10 minutes of MUF was performed without issue.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

n/a

ACTION TAKEN

Lessons learned:

Water lines were short, which caused the oxygenator to rotate anticlockwise, all arterial lines etc were exiting the oxygenator in a clockwise direction. This line remained patient with forward flow during the case. Whilst the arterial pump had been on during MUF, it was at a lower flow rate to the MUF pump, causing the line to close, exerting a negative pressure on the membrane. No air was able to travel up the arterial line and a bubble sensor was on throughout.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

062



1/8/20

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REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

REPORT NO

060



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REPORT NO

059



1/5/20

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REPORT NO

058



1/7/20

Centrifugal Head Issue 3

REPORT NO

057



1/6/20

Centrifugal Head Issue 2

REPORT NO

056



1/1/20

Centrifugal Head Issue

REPORT NO

055



1/2/20

Faulty Pressure Relief Valves

REPORT NO

054



1/4/20

Leaking ALF

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

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050



1/10/19

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REPORT NO

049



1/12/19

Oxygenation Issue

REPORT NO

048



1/8/19

Roller Pump Failure

REPORT NO

047



1/12/19

Broken Cannula Dilator

REPORT NO

046



6/12/19

Gas Blender Error

REPORT NO

045



20/11/19

Tubing Detachments

REPORT NO

044



27/11/19

Interruption to IABP counterpulsation

REPORT NO

043



1/7/19

Getinge Mal-Position Of IABP Catheter

REPORT NO

042



1/2/19

Avalon Dual Lumen Cannula Crack

REPORT NO

041



1/2/19

Custodial Rubber Fragmentation In Spiked Bag

REPORT NO

040



1/10/18

Reservoir Clot

REPORT NO

039



1/10/18

Pall Clot In Cardioplegia Circuit

REPORT NO

038



1/10/18

Maquet HL20 Cardioplegia Pump Error

REPORT NO

037



1/10/17

Temed D200 Haemoconcentrator Clot

REPORT NO

036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

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