Perfusion Glitches: Kink in Cardioplegia Line
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Event Description:
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.
The patient suffered no ill effects and did not fibrillate prematurely as a result of the delay.
How Was The Problem Identified?
High cardioplegia line pressures; very slow perfusate Q, heart wouldn’t arrest.
What Steps Were Taken ?
- A different delivery system was primed
- Spliced into recirc line.
- Lines reconnected, heart X-clamped & arrested : Issue Resolved
What Clues Were Missed?
There was a kink in the outlet tubing of the Quest that from the operators position was not easily seen. When the tubing was replaced in the line holder, the kink was still present (tubing memory).
A tie band was used as a “strut” to prevent the line from re-kinking as this problem recurred two days in a row. The tubing is very thin and pliant, and easily kinks.
The “Fix” on the next case.
Discussion:
This was a progression of decisions as a result of a partially kinked line that still allowed forward Q. The kink was undetectable to the operator even after checking the circuit multiple times.
Had there been no Q at all, the system would have been changed out before initiating bypass. The flow rate was assessed with the personnel at the field after repositioning the line into it’s inserts and reevaluating the system. At that time the performance seemed adequate.
On initiation of bypass the line seems to have settled back into it’s kink, even though it seemed like it was allowing forward Q.
Eventually the line re-kinked enough so that line pressures became the rate limiting factor, and reduced cardioplegia Q delivery to an ineffective level. The heart was not able to be arrested, and the decision to change out was made before the heart could fibrillate and the patient cooled.
The change out was effected with patient on bypass with beating heart. CAD and ischemia were not an issue.
Outcome:
- No issues.
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