International CQI: USA: Cardioplegia Line Kinked

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International CQI: USA: Cardioplegia Line Kinked

Event Description:

Double checked my ECC prior to a bypass run- had high line pressures when recirculating Quest MPS Cardioplegia delivery system.

Identified and fixed an obvious kink in the outlet line.

Have seen this many times before.

How Was The Problem Identified?

High line pressures when recirculating cardioplegia

What Steps Were Taken ?

  1. Tried to reposition line
  2. Placed a supporting splint to eliminate kink  Issue Resolved

What Clues Were Missed?

None:  Everything was double and triple checked.

Discussion:

This is not the first time I have seen this with this particular delivery system.  The kink occurs in the same spot every time.

Outcome:

  • No issues.

Comments:

  • Pending

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