PERFUSION REPORTS

REPORT

106

DATE

1/11/2022

TITLE

ECG Interference

DETAILS OF INCIDENT

Delivering blood cardioplegia initially stopped ECG activity as expected but we then was left with a regular waveform which would not go.

Aortic cross clamp was repositioned and more cardioplegiawas delivered. Still no flat line on the ECG.

Then the Registrar anaesthetist mentioned that the 'slurpslurp' sound from the sump sucker was in time with the ECG activity.

The keen hearing of the perfusionist picked this up andturned off the sump sucker and the ECG activity. Flat line at last..

Turning the sucker back on without the slurping did notreproduce the waveform.

We surmised that the loud 'slurp slurp slurp'was somehow sending a signal to the ECG. Possibly vibration..

DETAILS OF INJURY TO PATIENT

No injury

TYPE OF DEVICE/MANUFACTURER

not known

ACTION TAKEN

Cardioplegia delivery resulted in asystole. However, ECG then continued to display activity resulting in cross clamp being re-positioned and more cardioplegia being delivered. additional cardioplegia did not achieve asystole. further investigation showed activity was the result of sucker interference.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
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Detached bullet tip of sump-updated response Sep 2022

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