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

062



1/8/20

Human Factors Issue

REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

REPORT NO

060



1/8/20

Oxygenator Fibre Leak

REPORT NO

059



1/5/20

Failure to remove CO2 effectively

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

REPORT NO

050



1/10/19

Venous Cannula Damaged

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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