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