International CQI: Vaporizer Obstructing O2 Q

Forane vaporizer

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Event Description:

Just went on CPB, noticed loss of O2 Sats, and blood was turning dark. Disconnected Gas line from membrane oxygenator and realized there was no O2 flowing through the line. Turned off Forane vaporizer and could feel O2 flow through the line- reconnected to Oxy, and everything saturated well. Bypassed vaporizer for the duration of case and removed from service.

Have not seen this before.

How Was The Problem Identified?

Darkening blood, loss of sats.

What Steps Were Taken ?

  1. O2 Lines checked and reconnected, root cause identified,
  2. Forane vaporizer bypassed  Issue Resolved

What Clues Were Missed?

None:  Everything was double and triple checked.

Discussion:

After the case the lines are inspected, nothing seems to be clogged or kinked.  The vaporizeer allowed free passage of gas flow when in the “off position”, but when the dial was turned on- the gas pressure dropped to almost nothing.

Outcome:

  • No issues.

Comments:

  • Pending

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