Perfusion Glitches: Deprimed Cardioplegia Line

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Event Description:

Dear sir,

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.

Thank you for allowing me to share this event.

Joseph

How Was The Problem Identified?

  • Watched the line deprime.

What Steps Were Taken ?

  1. Lines reconnected
  2. De-aired via AO root vent Issue Resolved

What Clues Were Missed?

  • None: Everything was double and triple checked.

Discussion:

  • First time I ever saw that happen.

Outcome:

  • No issues.

Comments:

  • None

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