Perfusion Glitches: Re-Priming Venous Line: Air Bolus RA
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Event Description:
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 venous line (before it gets to the reservoir) that alows us either to RAP volume, or retrograde 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.
How Was The Problem Identified?
Notified by Surgeon and Scrub Team.
What Steps Were Taken ?
- Venous line disconnected from venous cannula
- Right atrium de-aired
- Venous line re-primed and reconnected : Issue Resolved
What Clues Were Missed?
The right atrium was re-cannulated first. The usual routine is Aorta and then Atrial.
Discussion:
This happened very quickly. Could have been avoided by keeping the line primed (simply chasing venous blood out with crystalloid). We have since modified our practice to ALWAYS leave the venous line primed.
Outcome:
- No fibrillation or patient injury.
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