Failed Hemonconcentrator: International CQI

CQI

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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.

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Event Description:

Dear sir,

Went on bypass, started hemoconcentrating and noticed immediately that the effluent from the Hemoconcentrator to the waste container was red tinged. I looked more closely at the fibers, and there appeared to be an area where they had ruptured. I took off about 1200 ml but stopped running the hemoconcentrator as the effluent was now pretty bloody,

Labs confirmed a high K+ consistent with hemolysis. There was also a collection of foam floating on top of the blood in the reservoir.  I informed anesthesia that the K was likely due to hemolysis- and it was treated with insulin and NaHCO3.

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How Was The Problem Identified?

  • Discoloration of hemoconcentrator effluent

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What Steps Were Taken ?

  1. Hemoconcentrator discontinued
  2. Insulin to treat increased K+
  3. Issue Resolved

What Clues Were Missed?

  • None: Everything was double and triple checked.

Discussion:

  • First time I ever saw that happen to this extent.  I believe that due to the ruptured fibers, the Q through the concentrator increased and contributed to the foam.  As well- the subsequent setup was altered to have the Hemoconcentrator empty via a FILTERED port- to help reduce this possibility.

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Outcome:

  • No issues.

Comments:

  • None

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