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 Join the CQI Registry: Click Here
- To Share a Perfusion Event: Click Here
- To View a Registry of Submitted Events: Click Here
- To Review Event Statistics: Click Here
- To Send an Email of the details of the event: Click Here
Want to Share a Problem or Unique Perfusion Issue?
email: [email protected]
(Click Image to View Summary of Glitches)
International Perfusion CQI: SpreadSheet Data
|Statement of the Problem ?||Timing of the Problem||Area of Concern||Personnel
|Root Cause Identified ?||Outcome||Patient Injury had Problem Been Undetected ?||Was the Patient Harmed ?||Potential Impact||Impact on You|
|Sucker Line Pressurized: Outlet Inadvertently Clamped : Pushed air forward||On Bypass||Equipment Setup Issue, Performance Issue||Perfusion, Circulating Team||Yes||Resolved Immediately||Yes||No||Could have gotten worse||Brushed 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 Bypass||Disposable Equipment Failure / Issue||Perfusion, Anesthesia||Yes||Cascaded to other problems||Yes||No||Could have gotten worse||Brushed 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 Bypass||Disposable Equipment Failure / Issue||Perfusion, Anesthesia||Yes||Cascaded to other problems||Yes||No||Could have gotten worse||Surprised 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 Bypass||Disposable Equipment Failure / Issue||Perfusion, Anesthesia||Yes||Resolved Immediately||Yes||No||Could have gotten worse||Surprised 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 Bypass||Disposable Equipment Failure / Issue||Perfusion||Yes||Resolved Immediately||No||No||Life Threatening||Surprised 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 Bypass||Mechanical Equipment Failure / Issue||Perfusion, Anesthesia||Yes||Resolved Immediately||Yes||No||Life Threatening||Shocked me|
|vvv||Pre Bypass||Disposable Equipment Failure / Issue||Perfusion, Anesthesia||Yes||Resolved Immediately||No||No||Life Threatening||Surprised 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.
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.
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 Bypass||Equipment Setup Issue, Performance Issue, Complication issue||Perfusion, Surgical Field||No||Resolved Immediately||Yes||No||It was a glitch but wondering how to prevent.||Scared me|
|N||On Bypass||Equipment Setup Issue||Perfusion, Anesthesia, Surgical Field||Yes||Cascaded to other problems||No||Unknown at this time||Serious but not life threatening||Why 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 risk of blood transfusion disease
|On Bypass||Surgical Issue||Surgical Field||Yes||Everything u say they will listen for short while n then return back||Yes||No||Reulted in Morbidity / Mortality||Some protocols should be there|
|Kinked Cardioplegia Tubing||Pre Bypass||Disposable Equipment Failure / Issue||Perfusion||Yes||Resolved Immediately||No||No||It was a glitch- No biggy||Brushed 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 Bypass||Equipment Setup Issue, Performance Issue, alertness||Perfusion, Surgical Field||Yes||Resolved Immediately||Yes||No||Life Threatening||Surprised me, caused it +found it=null|
|Noticed Decreased Pressure and Increased Venous Return While Maintaining Same Q Rate Using Arterial Roller Pump.||On Bypass||Equipment Setup Issue||Perfusion||Yes||Resolved Immediately||Yes||No||Could have gotten worse||Surprised me|
|not good conection from stopcock with arterial filter||Pre Bypass||Disposable Equipment Failure / Issue, Equipment Setup Issue||Perfusion||Yes||Resolved Immediately||Yes||No||Could have gotten worse||Surprised 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 Bypass||Equipment Setup Issue, Performance Issue||Perfusion, Surgical Field||Yes||Resolved Immediately||Yes||No||Life Threatening||Shocked 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 Bypass||Mechanical Equipment Failure / Issue, Disposable Equipment Failure / Issue, Equipment Setup Issue||Perfusion, Surgical Field, Circulating Team||Yes||Resolved Immediately||No||No||Life Threatening||Shocked me|
|de- priming of oxygenator during MUF||Post Bypass||Performance Issue||Perfusion||Yes||Cascaded to other problems||Undetermined||No||Serious but not life threatening||Tunnel 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 Bypass||Medication issue||Perfusion, Anesthesia, Surgical Field||Yes||Resolved Immediately||Yes||No||Serious but not life threatening||Shocked me|
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 Bypass||Mechanical Equipment Failure / Issue||Perfusion, Surgical Field||No||Unresolved||No||No||Serious but not life threatening||Surprised 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 Bypass||Equipment Setup Issue||Perfusion, Surgical Field||Yes||Resolved Immediately||Yes||No||Could have gotten worse||Surprised me|
|In some countries in latin America never bay hart long machine with out safe sistem||On Bypass||Equipment Setup Issue||Perfusion, Administration||Yes||Unresolved||No||No||Serious but not life threatening||Scared 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 Bypass||Disposable Equipment Failure / Issue||Perfusion||Yes||Resolved Immediately||No||No||It was a glitch- No biggy||Brushed it off|