International CQI: USA: Total Oxygenator Failure
Operation:
ACB x 3.
Pt. Data
- 70 years old
- Gender: Male
- 71 inches
- 79 Kilograms
- 1.94 BSA
- Baseline Hematocrit- 44%
Pertinant Hx:
- Unremarkable.
- No coagulopathic issues
- No other issues- patient appeared to be robust and healthy.
Plan:
ACB x 3: Mild Hypothermia- 34 degrees C..
Prime Constituents:
- 300 ml Normosol
- 5,000 units heparin
- 37.5 g Albumin
- 25 g Mannitol
- 50 meq NaHCO3
- Prime volume estimated at 1000 cc’s.
Approach:
- Oxygenator: Undisclosed
- Circuit: Standard
- Ultrafiltration concomitant with CPB
- 1% Forane on initiation of CPB
- 100% FiO2 2.2 liter sweep gas
- 4.0 to 5.0 Blood Q
- Cool to 34 C
- Antegrade Cardioplegia for onset and continuation of myocardial preservation.
Timeline:
On CPB [1]
- On Pump
- Drifting core temp to 34 degrees C
- + 1 minute: Noted that there was only a slight color difference in the brightness of the arterial blood when compared to the color of the venous blood
- Note that InVivo Arterial sensor indicates a PO2 of 90 and dropping fast
- Note that CO2 is in the high 80’s.
- FIO2 at 100% Sweep gas bumped to 5 LPM
- Surgeon notified that I need to come off CPB- because we aren’t saturating the patient. Surgeon makes comment about the color of the arterial blood.
- Anesthesia resumes ventilation, I fill the patient, BP- 140/80 and come off bypass. Pt Temp approx 35.5 degrees C.
- Pt isn’t cooled yet- no XC yet- so heart is beating, I inform surgeon I am coming off to evaluate the ECC- shunt blood back to the patient, Anesthesia resumes ventilating and we come off bypass with normal ejection and pressures.
Off CPB
I check the integrity of the ECC:
- Verify that O2 line is attached to Oxygenator.
- Double check Gas settings- 100% O2 & Sweep of 5 LPM
- Check O2 sat Monitor- which indicates 100% O2 coming from the gas lines.
Return to CPB [2]
- PO2’s still too low- on for about 45 seconds- and off again.
Off CPB
- Ask assistance from anesthesia- Dr. Jack S – to help me double check my circuit (especially the O2Delivery component) just to make sure I haven’t missed anything.
- I re-rout my blood Q through the recirc line- to see if the blood oxygenates at all- it doe pink up a bit.
- Dr Shannon and I do a series of manual tests- removing the O2 line from the Oxygenator to make sure that gas is indeed flowing through it. We both confirm that it does.
- Since the blood did “pink up” when recirculating it through the Oxygenator- it verifies at least some functionality- so I try CPB again.
Return to CPB [3]
- PO2’s still too low- on for about 45 seconds- and off again.
Off CPB
- To rule out a massive failure in our room O2 delivery system- I change the source to an external oxygen tank @ 100% and 5 LPM.
Return to CPB [4]
- PO2’s still too low- on for about 45 seconds- and off again.
- Decision is made to change out the oxygenator.
Off CPB
- Oxygenator is changed out
- Primed and deaired.
- Visual confirmation from surgical staff at the table that there is no air in the arterial line.
- Back on CPB
Return to CPB [5]
- PO2’s immediately bump up to 350 +
- PCO2 drops to normal limits.
- Cardioplegia is double checked for air- and hooked up-
- Aortic Crossclamp is placed on the aorta, heart is arrested, and the operation proceeds with no further incident.
CPB time- 60 minutes
XC Time- 30 minutes.
Hct on room departure- 30+
Chief Perfusionist, is notified and comes in to assist and evaluate.
CMC Risk Management is notified and takes possession of the failed oxygenator.
Membrane sent to Manufacturer for Review,
Manufacturer confirms that: there was a structural damage issue- not involving the membrane itself, that rendered the oxygenator useless.
Editors Note:
This is a new platform for Quality Improvement. We are trying to develop a database of common or not-so-common problems encountered by perfusionists during CPB. We are inviting perfusionists, groups, and institutional participation to develop a universal platform for identifying areas of concern in terms of Quality issues or trends encountered by perfusionists around the globe.
- Please join us by clicking the Link Here.
- If you have had an unusual event you would like to share. Click this link.
- Please email details if you feel that your story will help other perfusionists troubleshoot similar issues while on bypass… [email protected]
- To View all submitted cases relating to Perfusion Problem Solving: Click Here
My goal is to get 500 participants- American, Asian, European, all countries are invited.
In the process we shall develop an email contact list so that we can come to a consensus for how to design a universal CQI reporting platform. Once that is established, I believe we will be the tip of the spear for perfusion quality improvement.
At least take a look at it and see what you think. It’s easy, non-time consuming, a valuable CQI initiative, and TOTALLY anonymous.
Current List of Submitted Events:
Click Images to View Event Details
Current Survey Results
Participants in the International CQI Registry = [78]
To Join the International Perfusion CQI Registry- cick image above
=
| City | State | Country | |
| 1 | Bangladesh | Bangladesh | |
| 2 | Dhahran Saudi Arabia | Eastern province | Saudi Arabia |
| 3 | Dhahran Saudi Arabia | Eastern province | Saudi Arabia |
| 4 | bhopal | m.p. | India |
| 5 | Kolkata | West Bengal | India |
| 6 | West Jakarta | Indonesia | |
| 7 | United States | ||
| 8 | Egypt | ||
| 9 | muscat | Oman | |
| 10 | Hyderabad | Andhra Pradesh | India |
| 11 | Bangalore | Karnataka | India |
| 12 | Najaf | Perfusionist | Iraq |
| 13 | Taranto | Italy | Italy |
| 14 | bangalore | karanata | India |
| 15 | Kelowna | British Columbia | Canada |
| 16 | Skopje | Macedonia, the Former Yugoslav Republic | |
| 17 | Italy | ||
| 18 | Campobasso | Molise | Italy |
| 19 | Florence | Italy | |
| 20 | Italy | ||
| 21 | United States | ||
| 22 | Oklahoma City | Oklahoma | United States |
| 23 | sana’a | sana’a | Yemen |
| 24 | cosenza | europa | Italy |
| 25 | KAKINADA; VIJAYAWADA | ANDHRA PRADESH | India |
| 26 | Kyoto city | Kyoto | Japan |
| 27 | İzmir | Turkey | |
| 28 | Samarate | Italy | Italy |
| 29 | chandigrh | U.T | India |
| 30 | Jensen Beach | Florida | United States |
| 31 | davao city | Philippines | |
| 32 | Global City, Taguig | Philippines | |
| 33 | Dhaka | N/A | Bangladesh |
| 34 | bhopal | madhya pradesh | India |
| 35 | Najaf | PERFUSIONIST | Iraq |
| 36 | Napoli | Italy | |
| 37 | Belgaum | Karnataka | India |
| 38 | Bandar Sunway Petaling Jaya | Selangor | Malaysia |
| 39 | New Delhi | Delhi | India |
| 40 | thrissur | kerala | India |
| 41 | thrissur | kerala | India |
| 42 | Indore | Madhya Pradesh | India |
| 43 | Houston | Texas | United States |
| 44 | Houston | Texas | United States |
| 45 | Kolkata | West bengal | India |
| 46 | Fes | Morocco | |
| 47 | Illinois | United States | |
| 48 | BENGALURU | KARNATAKA | India |
| 49 | Caracas | D.C | Venezuela |
| 50 | BENGALURU | KARNATAKA | India |
| 51 | Lisbon | Lisbon | Portugal |
| 52 | United States | ||
| 53 | Lahore | Punjab(province) | Pakistan |
| 54 | Bogota | D.c. | Colombia |
| 55 | Amman | Jordan | |
| 56 | Grudziądz | Kujawsko-pomorskie | Poland |
| 57 | Taipei | Taiwan | |
| 58 | Taipei | Taiwan | |
| 59 | Hyderabad | Andhra pradesh | India |
| 60 | Belgium K |
Karnataka | India |
| 61 | Brussels | Belgium | |
| 62 | Bilaspur | Chhattisgarh | India |
| 63 | Caracas | Distrito Capital | Venezuela |
| 64 | Amman | Jordan | |
| 65 | Daytona beach | Florida | United States |
| 66 | Skopje,Macedonia | Macedonia, the Former Yugoslav Republic | |
| 67 | Thailand | ||
| 68 | Najaf | Perfusionist | Iraq |
| 69 | Najaf | Perfusionist | Iraq |
| 70 | Bangalore | Karnataka | India |
| 71 | Salem | tamilnadu | India |
| 72 | Tirana | Albania | Albania |
| 73 | Oslo | Norway | |
| 74 | Belgrade | Serbia | Serbia |
| 75 | Syrian Arab Republic | ||
| 76 | Italy | ||
| 77 | Najaf | Iraq | Iraq |
| 78 | Legnano | Milano | Italy |
