International Perfusion CQI: SpreadSheet Data

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Editors Note:

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. 

It’s really more of a registry of the odd things that can happen on bypass- as opposed to submitting a department report or seminal event.You know- the totally odd confluence of events that can lead to a snowball effect of potentially seriously hazardous exposure for the patient?

This is a report to assist in evaluating the complex decision making process we engage in, when encountering unexpected mechanical failures or clinical events.

Please maintain your utmost discretion regarding institutional and patient privacy issues.  They obviously vary from country to country, so remain oblique in any sort of dialogue that involves patient identifiers (time, place names, type of case, dates of operations, country, city, or state).

  • To View a Registry of Submitted Events:  Click Here
  • To Send an Email of the details of the event:  Click Here

Want to Share a Problem or Unique Perfusion Issue?

email:  EccLog@gmail.com

(Click Image to View Summary of Glitches)

International Perfusion CQI: SpreadSheet Data
Statement of the Problem ?Timing of the ProblemArea of ConcernPersonnel 

Involved…

Root Cause Identified ?OutcomePatient Injury had Problem Been Undetected ?Was the Patient Harmed ?Potential ImpactImpact on You
Sucker Line Pressurized: Outlet Inadvertently Clamped : Pushed air forwardOn BypassEquipment Setup Issue, Performance IssuePerfusion, Circulating TeamYesResolved ImmediatelyYesNoCould have gotten worseBrushed it off, Surprised me
Placed pt on bypass- started using my hemoconcentrator and noticed that the effluent was pink and getting more reddish. Observed K+ levels were rising and suspected hemolyses as the root cause. Also spotted foam at the top of my blood level.

Discontinued use of the hempconcentrator, administered NaHCO3 and insulin to preempt the rising potassium level. It was a quick run, so the decision was made to not splice in a new concentraor.

On BypassDisposable Equipment Failure / IssuePerfusion, AnesthesiaYesCascaded to other problemsYesNoCould have gotten worseBrushed it off
Went on bypass, started hemoconcentrating and noticed immediately the the effluent from the Hemoconcentrator to the waste container was red tinged. I looked more closely at the fibers, and there appeared to be an area where they had ruptured. I took off about 1200 ml but stopped running the hemoconcentrator as the effluent was now pretty bloody,

Labs confirmed a high K+ consistent with hemolysis. There was also a collection of foam floating on top of the blood in the reservoir.

On BypassDisposable Equipment Failure / IssuePerfusion, AnesthesiaYesCascaded to other problemsYesNoCould have gotten worseSurprised me
Went on bypass, started hemoconcentrating and noticed immediately that the effluent from the Hemoconcentrator to the waste container was red tinged. I looked more closely at the fibers, and there appeared to be an area where they had ruptured. I took off about 1200 ml but stopped running the hemoconcentrator as the effluent was now pretty bloody,

Labs confirmed a high K+ consistent with hemolysis. There was also a collection of foam floating on top of the blood in the reservoir. I informed anesthesia that the K was likely due to hemolysis- and it was treated with insulin and NaHCO3.

On BypassDisposable Equipment Failure / IssuePerfusion, AnesthesiaYesResolved ImmediatelyYesNoCould have gotten worseSurprised me
Began setting up for a morning case, this was a dry setup from the day before- noticed that the recirc line was separated at the junction point immediately proximal to where a one-way valve was usually in place. Looked closely- and the to ends were too loose to fit together. I believe it is usually a heat sealed connection. Cut the connections sites away- and reconnected recirc line with a 1/4″ x 1/4″ straight connector.Pre BypassDisposable Equipment Failure / IssuePerfusionYesResolved ImmediatelyNoNoLife ThreateningSurprised me
On CPB, loss of O2 Sats, and blood was turning dark. Disconnected Gas line from membrane oxygenator and reaalized there was no O2 flowing through the line. Turned off Forane vaporizer and could feel O2 flow through the line- reconnected to Oxy, and everything saturated well. Bypassed vaporizer for the duration of case and removed from service.On BypassMechanical Equipment Failure / IssuePerfusion, AnesthesiaYesResolved ImmediatelyYesNoLife ThreateningShocked me
vvvPre BypassDisposable Equipment Failure / IssuePerfusion, AnesthesiaYesResolved ImmediatelyNoNoLife ThreateningSurprised me
Air in the venous line just after cannulation (bi-caval, pediatric patient) and noted with initiation. When attempting to initate bypass after the insertion of all cannulas, I opened my venous line and had no drainage. There was blood noted in the cannula but air was seen (almost immediately) in the venous line to my circuit. I had not attempted to use vacuum to increase the drainage so I am unclear as to where the air came from.

I did do a differential diagnosis and came up with at least 6 options. The most common are, poor cannula position, loose snares around the cannula so air is pulled into the line around the snares and poor fluid to fluid connection when the cannula and venous line are connected.
This is not the first time I have encountered this problem.

The first time the entire line deprimed and needed to be reprimed retrograde to the field with a perfusion adapter a stopcock and 60 ml of Plyte.
This time I was able to pull the air lock through with the assistance of vacuum.

I am wondering if anyone has any other suggestions as to how to trouble shoot this problem or other suggestions as to how to prevent it.

Pre BypassEquipment Setup Issue, Performance Issue, Complication issuePerfusion, Surgical FieldNoResolved ImmediatelyYesNoIt was a glitch but wondering how to prevent.Scared me
NOn BypassEquipment Setup IssuePerfusion, Anesthesia, Surgical FieldYesCascaded to other problemsNoUnknown at this timeSerious but not life threateningWhy do I do this to myself ?
Use of extra water during surgeon taking knot of suture causing hemodilution low svr poor o2 delivery adding of homologous blood
Increasing sirs
Increasing risk of blood transfusion disease
On BypassSurgical IssueSurgical FieldYesEverything u say they will listen for short while n then return backYesNoReulted in Morbidity / MortalitySome protocols should be there
Kinked Cardioplegia TubingPre BypassDisposable Equipment Failure / IssuePerfusionYesResolved ImmediatelyNoNoIt was a glitch- No biggyBrushed it off
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”.
Pre BypassEquipment Setup Issue, Performance Issue, alertnessPerfusion, Surgical FieldYesResolved ImmediatelyYesNoLife ThreateningSurprised me, caused it +found it=null
Noticed Decreased Pressure and Increased Venous Return While Maintaining Same Q Rate Using Arterial Roller Pump.On BypassEquipment Setup IssuePerfusionYesResolved ImmediatelyYesNoCould have gotten worseSurprised me
not good conection from stopcock with arterial filterPre BypassDisposable Equipment Failure / Issue, Equipment Setup IssuePerfusionYesResolved ImmediatelyYesNoCould have gotten worseSurprised me
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 alows us either to RAP volume, or retrgrade 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.

The patient suffered no ill effects and did not fibrillate prematurely as a result of the air.

Pre BypassEquipment Setup Issue, Performance IssuePerfusion, Surgical FieldYesResolved ImmediatelyYesNoLife ThreateningShocked me, Scared me
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.

Pre Bypass, On BypassMechanical Equipment Failure / Issue, Disposable Equipment Failure / Issue, Equipment Setup IssuePerfusion, Surgical Field, Circulating TeamYesResolved ImmediatelyNoNoLife ThreateningShocked me
de- priming of oxygenator during MUFPost BypassPerformance IssuePerfusionYesCascaded to other problemsUndeterminedNoSerious but not life threateningTunnel Vision Time …
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.On BypassMedication issuePerfusion, Anesthesia, Surgical FieldYesResolved ImmediatelyYesNoSerious but not life threateningShocked me
Vacuum Interruption

The surgeon says go on bypass, you unclamp your lines, check your line pressure, turn on the vacuum and nothing! It worked a few moments ago, you turn it on and off, still no vacuum supply. The heart is distended , you turn your flow down, check your supply lines, make sure the vacuum is connected, still no supply! Then magically after connecting and reconnecting the supply lines in the boom a few times the vacuum turns back on!

On BypassMechanical Equipment Failure / IssuePerfusion, Surgical FieldNoUnresolvedNoNoSerious but not life threateningSurprised me
I recently encountered a problem with my cardioplegia line depriming following my initial arresting dose.

It was during the middle of the first distal anastamosis, and I took the clamp off of my cardioplegia line to reposition it. It immediately filled with air. I was shocked because the line was still occluded by the delivery system, so I thought perhaps my aortic root vent was on too high and had created a strong enough negative pressure to pull air out of solution (blood).

As it turned out, my luerlock connection was off by a pinprick- and just loose enough to pull air (negative pressure from vent line) through it when I momentarily moved my clamp.

I re-tightened the connection and I informed the surgeon. We reprimed the line by flushing the air out through the root vent.

On BypassEquipment Setup IssuePerfusion, Surgical FieldYesResolved ImmediatelyYesNoCould have gotten worseSurprised me
In some countries in latin America never bay hart long machine with out safe sistemOn BypassEquipment Setup IssuePerfusion, AdministrationYesUnresolvedNoNoSerious but not life threateningScared me
Water line leaked after attaching to Oxygenator. This is the 3rd time I have seen this. Observed what appears to be a mold deformity on the H2O outlet from the Oxygenator, distorted inwardly so that a water tight fit is not possible.Pre BypassDisposable Equipment Failure / IssuePerfusionYesResolved ImmediatelyNoNoIt was a glitch- No biggyBrushed it off