PERFUSION REPORTS

REPORT
091
DATE
1/10/2021
TITLE
Oyxgenator Leak
DETAILS OF INCIDENT

A leak was observed emanating from the bottom of an Affinity Fusion oxygenator through two of the vents of the gas exhaust. The leak was observed during cardiopulmonary bypass a few minutes after cross clamp was applied for AVR surgery. Closer inspection revealed foamed blood widespread across the bottom of the oxygenator which was obscured the source of the leak. The leak was estimated to be approx 2-3mls/min. No change in arterial line pressure, blood gas values, or aptient haemodynamics was apparent before or after detection of the leak, or throughout the case that could be attributed to the leak. There was also no evidence of additional leaks, air entrainment or haemolysis.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Medtronic Fusion Oxygenator-custom circuit.

Date of manufacture: Sep 2021

ACTION TAKEN

Both the consultant anaesthetist and surgeon were informed of the leak. Based on this experience and the assessment of the severity of the leak it was decided to continue with the operation and wean from bypass at the earliest and safest stage of the operation. The decision to continue bypass rather than perform an oxygenator changeout was deemed to have the least risk based on the nature of the leak i.e. minimal blood loss, leak from blood to gas phase. Regular monitoring of the leak was performed until the bypass was terminated. No effect on the function of the oxygenator was observed.

RESPONSE FROM MANUFACTURER

Awaiting response

ADDTIONAL INFORMATION

Appropriate agency informed

SUPPORTING VISUALS/VIDEO
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
032
Sucker Placed In Raceway In Wrong Direction
REPORT NO
031
High Transmembrane Pressure Gradients
REPORT NO
030
Faulty Connector On ECMO Soft Shell Reservoir Bag
REPORT NO
029
Sorin Inspire 8F Blood Leak From Temperature Port
REPORT NO
028
Sorin Inspire 8F Oxygenator Detached From Holding Arm
REPORT NO
027
Paragon Oxygenator Gas Inlet Leak
REPORT NO
026
Maquet IABP Console Failure
REPORT NO
025
Sorin EOS Gas To Blood Leak Whilst Priming
REPORT NO
024
Chalice Paragon Midi Heat Exchanger Leak Whilst Priming
REPORT NO
023
Chalice Paragon Heat Exchanger Water To Blood Leak
REPORT NO
022
Vent Pump Boot Tubing Inserted In Wrong Way Round
REPORT NO
021
Paragon Oxygenator Heat Exchanger Leak
REPORT NO
020
S3 E62 Pump Error
REPORT NO
019
Medtronic Potential Oxygenator Leak
REPORT NO
018
Medos Heat Exchanger Leak
REPORT NO
017
Avant D903 Has A Dual Chamber Reservoir Leak
REPORT NO
016
Additional Sucker Incorrectly Placed In Raceway
REPORT NO
015
Large Perished Tear Observed On Tubing At Back Of Vaporiser
REPORT NO
014
Gas Blender Flow Control Immobilised
REPORT NO
013
Isoflurane Vaporiser Seal Leak Due To Malposition
REPORT NO
012
1/2/13
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
011
1/1/13
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
010
1/3/12
Sucker Placed In Raceway In Wrong Direction
REPORT NO
009
1/2/12
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
008
1/7/11
Aorta Remained Clamped Post CPB
REPORT NO
007
1/5/11
Deficiencies In The QC At Terumo Ann Arbor, USA.
REPORT NO
006
1/4/11
Awareness Of Suckers When Using Bio-Glues
REPORT NO
005
1/2/11
Patient Exsanguinated From Additional Venous Line Post CPB
REPORT NO
004
1/1/11
Possible Inaccuracies In Colloid Research
REPORT NO
003
1/2/10
Difficulties In Visualising Blender Reading
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.