Perfusion Glitches: Fatigue & Air in Arterial Line

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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 has 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…

Event Description:

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. 

How Was The Problem Identified?

Last Second Visual Scan by Perfusionist.

What Steps Were Taken ?

  1. Arterial Line Re-Primed:  Issue Resolved

What Clues Were Missed?

Hooked one (of two) filter vents to wrong little hole—into the oxy/card instead of sampling manifold. 

Discussion:

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”.

Outcome:

  • Could have been catastrophic:  No Harm- No Foul

Want to Share a Problem or Unique Perfusion Issue?

email:  EccLog@gmail.com

(Click Image to View Summary of Glitches)

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