REPORT
040
DATE
Mar 2019
TITLE
Gas Line Filter Issue
DETAILS OF INCIDENT

On-going problem with Liva Nova green gas line with filter since November 2018 (at least 10 gas lines that reported department are aware of).  

Noticed pre-CPB when checking gas flow through gas line, pressure readings over 30mmHg on Maquet electronic gas blender.  When gas sweep increased it alarmed at 50mmHg.  When the gas line filter was disconnected the pressure returned to 0.

This has happened numerous times when using different Maquet electronic gas blenders (EGB 40).  It was not noted when using Sechrist blenders as pressure readings are not available on these blenders.  

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Liva Nova gas line

Product Code: CP8049

Ref: 08049

ACTION TAKEN

Reported to Liva Nova. 6 gas lines that were deemed faulty were collected by Liva Nova for further investigation.

Liva Nova have supplied an alternative gas line filter (Pall) in case further issues arise while using the Maquet electronic gasblender.  When using the Sechrist blenders and the Liva Nova custom pack the gas line is automatically swapped for a Pall gas line.  

RESPONSE FROM MANUFACTURER

See attached below

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

The issues was always identified prior to going on CPB so no patient was put at risk.  Members of the perfusion team were informed quickly so all were aware and able to keep defective items.  It was reported quickly to Liva Nova.  

The team reflected on the use of gas blenders without the ability to notice pressure changes within the line.  

New action plans/changes as a result of the event?

Liva Nova custom packs going forward will only be supplied with Pall gas line filter.  

SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION REPORTS

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
REPORT NO
049
DATE
August 2020
LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE
REPORT NO
048
DATE
August 2020
Oxygenator Fibre Leak
REPORT NO
047
DATE
May 2020
Failure to remove CO2 effectively
REPORT NO
046
DATE
July 2020
Centrifugal Head Issue 3
REPORT NO
045
DATE
June 2020
Centrifugal Head Issue 2
REPORT NO
044
DATE
Jan 2020
Centrifugal Head Issue
REPORT NO
043
DATE
Feb 2020
Faulty Pressure Relief Valves
REPORT NO
042
DATE
Apr 2020
Leaking ALF
REPORT NO
041
DATE
Feb 2020
Arterial Line Filter Leak
REPORT NO
040
DATE
Mar 2019
Gas Line Filter Issue
REPORT NO
039
DATE
Dec 2019
Dual Lumen Cannula Movement
REPORT NO
038
DATE
Oct 2019
Venous Cannula Damaged
BACK TO SAFETY ARCHIVE