Failed Hemonconcentrator: International CQI
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Event Description:
Dear sir,
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.
How Was The Problem Identified?
- Discoloration of hemoconcentrator effluent
.
What Steps Were Taken ?
- Hemoconcentrator discontinued
- Insulin to treat increased K+
- Issue Resolved
What Clues Were Missed?
- None: Everything was double and triple checked.
Discussion:
- First time I ever saw that happen to this extent. I believe that due to the ruptured fibers, the Q through the concentrator increased and contributed to the foam. As well- the subsequent setup was altered to have the Hemoconcentrator empty via a FILTERED port- to help reduce this possibility.
Outcome:
- No issues.
Comments:
- None
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