PERFUSION REPORTS

REPORT

105

DATE

9/9/2022

TITLE

Issue with use of disposable

DETAILS OF INCIDENT

Going on bypass with small adult circuit, I was struggling with venous return into reservoir. There was probably a large amount of sucker volume being returned.

Raised concerns with surgeon and anaesthetist, used Hartmann's to maintain flow for approx 5 minutes.

Called for help, 1 o/c perfusionist attended and found the issue was with the reservoir sequestration valve being closed, possibly during priming or handing up of the lines due to its position on the reservoir.

Full flow was re-established. Cross clamp was applied and cardioplegia given along with patient cooling. There were no further complications.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Inspire 6F Dual chamber reservoir

ACTION TAKEN

As above-sequestration valve opened and flow established

RESPONSE FROM MANUFACTURER

None required

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

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

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