PERFUSION REPORTS

REPORT

096

DATE

18/3/2022

TITLE

Bubbles Sensor Activation

DETAILS OF INCIDENT

Arterial line bubble sensors have been activated recently during CPB support. No evidence of any air was detected and CPB reinstituted. This has now occurred at least on 6 separate occasions. This has occurred with different HLM's - all of which are S5.

There have also been incidents, whereby the venous reservoir level sensor has been activated, despite adequate levels of blood within the reservoir.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Liva Nova S5 HLM's

Liva Nova level sensors

‍

ACTION TAKEN

Local medical physics team in discussions with Liva Nova to investigate findings. A number of arterial bubble sensors have been replaced.

RESPONSE FROM MANUFACTURER

waiting

ADDTIONAL INFORMATION

Safety Committee Note to S5 users:

Users of S5 HLM should check the bubble sensor pillows and replace at regular intervals, as recommended by the manufacturer/servicing department.

Bubble sensor pillows flatten over time and this can cause bubble sensor activation despite no obvious emboli.

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

Picture of flattened bubble sensor pillows

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

123



5/7/24

Hardware Fault

REPORT NO

122



5/4/24

Oxygenator Failure

REPORT NO

121



8/3/24

Disposables: Eurosets Adult ECMO Oxygenator

REPORT NO

120



1/5/24

Disposable Incident

REPORT NO

119



Hardware: HCU Contamination

REPORT NO

118



12/9/23

Human Factors: ECMO Mobilisation

REPORT NO

117



27/9/23

Disposables: Oxygenator

REPORT NO

116



14/9/23

Disposable Issue: Reservoir in CPB circuit

REPORT NO

115



13/9/23

Disposable Error

REPORT NO

114



13/7/23

Dispoables

REPORT NO

112



20/2/23

HLM Hardware Error: S5 HLM - Dual roller cardioplegia

REPORT NO

111



10/2/23

Human Factors

REPORT NO

110



31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

Detached bullet tip of sump-updated response Sep 2022

Perfusion Report cards are shown in batches of 30 at any one time where available.

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