International CQI: USA: Total Oxygenator Failure

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Operation:

ACB x 3.

Pt. Data

  • 70 years old
  • Gender: Male
  • 71 inches
  • 79 Kilograms
  • 1.94 BSA
  • Baseline Hematocrit- 44%

Pertinant Hx:

  • Unremarkable.
  • No coagulopathic issues
  • No other issues-  patient appeared to be  robust and healthy.

Plan:

ACB x 3:  Mild Hypothermia- 34 degrees C..

Prime Constituents:

  • 300 ml  Normosol
  • 5,000 units heparin
  • 37.5 g Albumin
  • 25 g Mannitol
  • 50 meq NaHCO3
  • Prime volume estimated at 1000 cc’s.

 Approach:

  • Oxygenator: Undisclosed
  • Circuit:  Standard
  •  Ultrafiltration concomitant with CPB
  • 1% Forane on initiation of CPB
  • 100%  FiO2 2.2 liter sweep gas
  • 4.0 to 5.0  Blood Q
  • Cool to 34 C
  • Antegrade Cardioplegia for onset and continuation of myocardial preservation.

Timeline:

Troubleshooting

On CPB [1]

  • On Pump
  • Drifting core temp to 34 degrees C
  • + 1 minute:  Noted that there was only a slight color difference in the brightness of the arterial blood when compared to the color of the venous blood
  • Note that InVivo Arterial sensor indicates a PO2 of 90 and dropping fast
  • Note that CO2 is in the high 80’s.
  • FIO2 at 100%  Sweep gas bumped to 5 LPM
  • Surgeon notified that I need to come off CPB- because we aren’t saturating the patient.  Surgeon makes comment about the color of the arterial blood.
  • Anesthesia resumes ventilation, I fill the patient, BP- 140/80  and come off bypass.  Pt Temp approx 35.5 degrees C.
  • Pt isn’t cooled yet- no XC yet- so heart is beating, I inform surgeon I am coming off to evaluate the ECC- shunt blood back to the patient, Anesthesia resumes ventilating and we come off bypass with normal ejection and pressures.

Off CPB

I check the integrity of the ECC:

  • Verify that O2 line is attached to Oxygenator.
  • Double check Gas settings- 100% O2 & Sweep of 5 LPM
  • Check O2 sat Monitor- which indicates 100% O2 coming from the gas lines.

Return to CPB [2]

  • PO2’s still too low- on for about 45 seconds- and off again.

Off CPB

  • Ask assistance from anesthesia- Dr. Jack S – to help me double check my circuit (especially the O2Delivery component) just to make sure I haven’t missed anything.
  • I re-rout my blood Q through the recirc line- to see if the blood oxygenates at all- it doe pink up a bit.
  • Dr Shannon and I do a series of manual tests- removing the O2 line from the Oxygenator to make sure that gas is indeed flowing through it.  We both confirm that it does.
  • Since the blood did “pink up” when recirculating it through the Oxygenator- it verifies at least some functionality- so I try CPB again.

Return to CPB [3]

  • PO2’s still too low- on for about 45 seconds- and off again.

Off CPB

  • To rule out a massive failure in our room O2 delivery system- I change the source to an external oxygen tank @ 100% and 5 LPM.

Return to CPB [4]

  • PO2’s still too low- on for about 45 seconds- and off again.
  • Decision is made to change out the oxygenator.

Off CPB

  • Oxygenator is changed out
  • Primed and deaired.
  • Visual confirmation from surgical staff at the table that there is no air in the arterial line.
  • Back on CPB

Return to CPB [5]

  • PO2’s immediately bump up to 350 +
  • PCO2 drops to normal limits.
  • Cardioplegia is double checked for air- and hooked up-
  • Aortic Crossclamp is placed on the aorta, heart is arrested, and the operation proceeds with no further incident.

Changeout

CPB time- 60 minutes

XC Time- 30 minutes.

Hct on room departure- 30+

Chief Perfusionist, is notified and comes in to assist and evaluate.

CMC Risk Management is notified and takes possession of the failed oxygenator.

Membrane sent to Manufacturer for Review,

Manufacturer confirms that: there was a structural damage issue- not involving the membrane itself, that rendered the oxygenator useless.

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Editors Note:

This is a new platform for Quality Improvement. We are trying to develop a database of common or not-so-common problems encountered by perfusionists during CPB.  We are inviting perfusionists, groups, and institutional participation to develop a universal platform for identifying areas of concern in terms of Quality issues or trends encountered by perfusionists around the globe.

  • If you have had an unusual event you would like to share. Click this link.
  • Please email details if you feel that your story will help other perfusionists troubleshoot similar issues while on bypass…  ecclog@gmail.com
  • To View all submitted cases relating to Perfusion Problem Solving: Click Here

My goal is to get 500 participants- American, Asian, European, all countries are invited.

In the process we shall develop an email contact list so that we can come to a consensus for how to design a universal CQI reporting platform.  Once that is established, I believe we will be the tip of the spear for perfusion quality improvement.

At least take a look at it and see what you think.  It’s easy, non-time consuming, a valuable CQI initiative, and TOTALLY anonymous.

Current List of Submitted Events:

Click Images to View Event Details

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Current Survey Results

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Participants in the International CQI Registry = [78]

Transfer 1

To Join the International Perfusion CQI Registry-  cick image above

=

City State Country
1 Bangladesh Bangladesh
2 Dhahran Saudi Arabia Eastern province Saudi Arabia
3 Dhahran Saudi Arabia Eastern province Saudi Arabia
4 bhopal m.p. India
5 Kolkata West Bengal India
6 West Jakarta Indonesia
7 United States
8 Egypt
9 muscat Oman
10 Hyderabad Andhra Pradesh India
11 Bangalore Karnataka India
12 Najaf Perfusionist Iraq
13 Taranto Italy Italy
14 bangalore karanata India
15 Kelowna British Columbia Canada
16 Skopje Macedonia, the Former Yugoslav Republic
17 Italy
18 Campobasso Molise Italy
19 Florence Italy
20 Italy
21 United States
22 Oklahoma City Oklahoma United States
23 sana’a sana’a Yemen
24 cosenza europa Italy
25 KAKINADA; VIJAYAWADA ANDHRA PRADESH India
26 Kyoto city Kyoto Japan
27 İzmir Turkey
28 Samarate Italy Italy
29 chandigrh U.T India
30 Jensen Beach Florida United States
31 davao city Philippines
32 Global City, Taguig Philippines
33 Dhaka N/A Bangladesh
34 bhopal madhya pradesh India
35 Najaf PERFUSIONIST Iraq
36 Napoli Italy
37 Belgaum Karnataka India
38 Bandar Sunway Petaling Jaya Selangor Malaysia
39 New Delhi Delhi India
40 thrissur kerala India
41 thrissur kerala India
42 Indore Madhya Pradesh India
43 Houston Texas United States
44 Houston Texas United States
45 Kolkata West bengal India
46 Fes Morocco
47 Illinois United States
48 BENGALURU KARNATAKA India
49 Caracas D.C Venezuela
50 BENGALURU KARNATAKA India
51 Lisbon Lisbon Portugal
52 United States
53 Lahore Punjab(province) Pakistan
54 Bogota D.c. Colombia
55 Amman Jordan
56 Grudziądz Kujawsko-pomorskie Poland
57 Taipei Taiwan
58 Taipei Taiwan
59 Hyderabad Andhra pradesh India
60 Belgium
K
Karnataka India
61 Brussels Belgium
62 Bilaspur Chhattisgarh India
63 Caracas Distrito Capital Venezuela
64 Amman Jordan
65 Daytona beach Florida United States
66 Skopje,Macedonia Macedonia, the Former Yugoslav Republic
67 Thailand
68 Najaf Perfusionist Iraq
69 Najaf Perfusionist Iraq
70 Bangalore Karnataka India
71 Salem tamilnadu India
72 Tirana Albania Albania
73 Oslo Norway
74 Belgrade Serbia Serbia
75 Syrian Arab Republic
76 Italy
77 Najaf Iraq Iraq
78 Legnano Milano Italy

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