PERFUSION REPORTS

REPORT

099

DATE

20/4/2022

TITLE

Human Factors: BiVAD Error

DETAILS OF INCIDENT

A 53 year old male in critical cardiogenic shock was taken to theatre for temporary mechanical circulatory support with CentriMag left and right ventricular assist devices.

A mistake occurred during the set-up of the CentriMag pumps. The motor cable of the LVAD was connected to the RVAD console and the motor cable of the RVAD was connected to the LVAD console.

The patient was established on BiVAD support.

There was imbalanced flow, with RVAD flow higher than LVAD flow. Attempts to increase LVAD flow had the opposite effect but the flow imbalance was well tolerated for two hours.

The patient then developed very low LVAD flow and a rising oxygen requirement. The left ventricle was not adequately unloaded on TOE. The initial working diagnosis was malposition of the aortic cannula and this was re-positioned. The actual cause of the problem was identified and corrected after three hours.

DETAILS OF INJURY TO PATIENT

See report attached.

TYPE OF DEVICE/MANUFACTURER

CentriMag BiVAD

ACTION TAKEN

See comprehensive report attached

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

Report-Bi VAD Human Factors

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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