Click Image Above to Add a “Episode” to the Perfusion Event Database …
This is a new Section. We are trying to develop a database of common or not-so-common problems encountered by perfusionists during CPB.
This is not an “Incident Report” section.
So Anyway, although the responses are not great in number- they do reveal a lot- and are good read in terms of identifying potential hazards before they surface.
The Clinical Scenarios
Air In Arterial Line
Up all night; felt fine. Had to adapt soft shell system to vacuum. Lots of little lines and details to figure. Hooked one (of two) filter vents to wrong little hole—into the oxy/card instead of sampling manifold. Surgeon uses a cannula attachment technique whereby we pump to the field, vs. letting the arterial cannula fill a clamped line. If the latter, no problem occurs: immediate recognition of error at start of bypass ( no CDI flow) and easy fix. Using the pump to method, somehow blood got pumped to but the surgeon let a foot of air get into the a-line and no one at the field noticed. Routine last minute scan of everything revealed air; perfusionist alerts, problem discovered; fixed; uneventfull bypass.
Of note: fatigue a factor? Two things needed for error to be dangeous. System seemed to function well on its own (recirulating). Reference “invisible gorilla test” for explantion of how a foot long air bubble went un-noticed by three people working over it. Check both filters with back pressure gauge when checking if cannula is functioning well (leuco and normal, in our case.) Read Gawande’s “Checklist Manifesto”.
Under-Occlusion of Rollerhead
Noticed Decreased Pressure and Increased Venous Return While Maintaining Same Q Rate Using Arterial Roller Pump.
Air Introduced to Right Atrium
We had come off bypass and were decannulated. The patient crashed and we had to recannulate to get back on bypass in a hurry. The venous line was de-primed, but we have a spike at the base of the line before that allows us either to RAP volume, or retrograde fill the venous line by squeezing a bag of Normosol attached to the spiked line and pushing the prime up the venous line to the patient.
Was in the process of doing that when the surgeon connected the line to the venous cannuala and a column of air was pushed forward into the right atrium.
We disconnected the line- squeezed as much air out as possible, primed the venous line with an asepto, and went on bypass.
Unseen Kink in Cardioplegia Line
Connected Quest MPS cardioplegia lines to the table- kept getting high pressure alarm shutoff when priming line to the table. Made sure line wasn’t clamped at the field, took tubing out of bubble detector and on/off clamp. No blocks or crimps noted.
Ran the prime up and got good flow.
On initiation of bypass- and X-Clamp, noticed high pressure alarm go off again, and very limited Q with 300 + mmHg pressures. Notified surgeon to remove X-clamp (heart was still beating and pt was not yet cooled.
Cut in a new MP4 system, re X-clamped, and the heart arrested.
Clamped Outlet of Sucker Line
Sucker Line Pressurized: Outlet Inadvertently Clamped : Pushed air forward as the back pressure overcame the pump occlusion-
Patient Wakes up While on Bypass
While on bypass my patient began to wake up approximately 13 mins,. into the pump run. Anesthesiologist had left the room for his extended break. Forane had to be maxed out at 5% because the patient was now trying to sit up and due to the fact the anesthesiologist had not responded to his beeper or phone calls. Upon finally re-entering room, he blamed perfusion for the waking up of the patient initially stating not enough Forane had been on. This particular Dr. does not put a BISS on the patient either. Says they are useless.
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