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

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