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. 


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”.


  • Could have been catastrophic:  No Harm- No Foul

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4 thoughts on “Perfusion Glitches: Fatigue & Air in Arterial Line

  1. Aye, matey, there is the rub.

    Until two weeks ago we used VAVD for one of three surgeons, and only if he were doing a mitral repair or replacement. With three perfusionists it means one can go a long time (four months in my case) without having to make the conversion from the normal to the special.

    A well trained muscian can play most anything by sight; but to be really good at it requires some practice. And no matter how well trained the muscian, if there has been a long hiatus from playing, the music will tell the tale.

    When approaching a new set up, I believe your expression is right on—it is hard to visualize all the changes and their reprecussions. Specifically here, in rearranging the bypass lines, hemoconcentrator feed, pressure manomenter, cardioplegia overpresurre vent and filter vents—-all those luer tipped lines—-and integrating them with the sampling manifold, while dealing with a number of interruptions, I passed my level of competence and slipped a filter vent into the cardiotomy—-a female luer port without a stopcock, whereas the line usually goes to the sampling manifold, which is closed per our check list.

    It is always the unexpected that traps us. Mixing up a luer line will never trip me up again. But something will. Something unforeseen. Which is why a forum like this is helpful—perhaps I will see something here and say “Yikes! I could have done that”, and will therefore be aware and avoid it.

    I also again encourage us all to read Atul Gawande’s “Checklist Manifesto”. He is a doc and one of our very best science writers.

    I also encourge, again, viewing the “invisible gorilla test” and reading one of the many studies on the phenomenom.

    Paul Friday keeps saying “Perception is Reality”, and I agree; but we can go a step backwards and observe that “Belief is Perception”. What we believe is what we see, what we glean from our experience, what we prognosticate. If you really want to examine the this, look for Michael Shermer’s “The Believing Brain”.

    “Nuff said.

  2. In this game there is always something waiting to trip us up, and it is often the smallest least likely thing.
    That’s why (I guess also being an ‘older’ Perfusionist), I try to follow (where allowed) the “KISS Principle” (Keep It Simple Stupid!)
    Thanks for sharing with us.

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