PERFUSION REPORTS

REPORT

112

DATE

20/2/2023

TITLE

HLM Hardware Error: S5 HLM - Dual roller cardioplegia

DETAILS OF INCIDENT

All pre-bypass checks complete. Bypass initiated, cross clamp applied and retrograde cardioplegia administration started. Unable to get sufficient flow rate due to coronary sinus pressure therefore stopped and moved to attempt antegrade cardioplegia via aortic root. When cardioplegia started the S5 console alarmed and displayed 'Pump malfunction' and it was noted that the crystalloid pump of the dual pump cardioplegia pump was not spinning.

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Surgeon immediately informed that there was a serious failure and we were unable to deliver cardioplegia.

DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

S5 Double Roller Pump85 / SN10E53864/ Date of Manufacture 2016-02-22

ACTION TAKEN

Surgeon immediately informed that there was a serious failure and we were unable to deliver cardioplegia. Cross clamp was removed and the heart was re-perfused. The cardioplegia pump was power cycled in isolation, testing was carried out and found that the issue had resolved. The decision was made to continue with the operation, which otherwise was uneventful.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

The safety committee has reviewed this incident and acknowledge that the older S5 pumps may have a trend with software errors that can account for these issues. Age and life span of the pump is something that must be monitored along with the incident rate and problems.

However, the pump was acquired in Feb 2016, so 7 years old.There have been no further issues with the pump. All pumps are regularlyserviced and maintained.

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