On establishing cardiopulmonary bypass the surgical team became aware that air had entered the heart after noting the presence of an air bubble within the cardioplegia cannula. The visible air was cleared at the time and the operation continued.
Post-operatively, it became evident that the Patient had sustained a hypoxic brain injury. The cause was identified as a significant air embolism during the institution of bypass. It was later established that the LV vent had been configured such that it temporarily blew air into the left ventricle.
The patient did not regain consciousness post-operatively. Following repeated CT scanning and clinical reviews, the prognosis was felt to be extremely poor. Treatment was withdrawn and the patient died. The root causes were human error and equipment factors. Human factors were also contributory.
The safety committee recognises the potential for human error and recommends all users of the S3 pump to raise awareness of the potential to inadvertently reverse the flow on these pumps. The wet table test of all suckers should be standard to avoid errors. Wet testing of vents prior to insertion will further increase the safety of these devices. The introduction of one way valves to the vent lines should be considered. Communication within the theatre team should always be a priority and without barriers.
