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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.
Please join us by clicking the Link Above if you have had any sort of unusual event you would like to share. Please email details if you feel that your story will help other perfusionists troubleshoot similar issues while on bypass…
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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.
- 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.
- No issues.
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