Perfusion Glitches: Pressurized Sucker Line
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Event Description:
Sucker line became pressurized due to outlet clamp (at the reservoir inlet) being clamped. Since the sucker raceway isn’t 100% occluded, the resulting pressurization of room air once the sucker roller pump was turned on, sent gas forward to the surgical field.
How Was The Problem Identified?
Sucker was blowing instead of sucking. First Instinct was to assume the lines were reversed.
What Steps Were Taken ?
- Sucker occlusion was readjusted: That failed
- Outlet clamping of sucker was identified: Issue Resolved
What Clues Were Missed?
Sucker lines occlusions were tested, but the fact that they were making a “Popping noise” (similar to what we hear when a sucker is occluded at the field) failed to alert the operator that there was an issue.
Discussion:
This perfusion group uses an extra line coming off their sucker at the end of the case to chase blood out of the ECC. At the end of the case the arterial line is connected to the sucker line, and the volume is chased out of the ECC via 1/4 ” line to the cell saver reservoir.
A customized clamp is fitted on the outlet of the sucker line between the reservoir and the attached 1/4 ” line and at the end of the case, is clamped to divert chased volume from the reservoir to the cell saver.
This clamp was inadvertently depressed during ECC setup, and obstructed any return to the reservoir from the sucker line- thus pressurizing it.
Outcome:
- No Harm- No Foul
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