PERFUSION REPORTS

REPORT
065
DATE
1/9/2020
TITLE
Intra Aortic Balloon Pump (IABP) Failure
DETAILS OF INCIDENT

The IABP was attached to a patient using a 7Fr 40cc Sensation fibre optic IABC. Perfusion were called in to review the IAB due to the diastolic digital pressures displaying as zero on the console despite the IAB clearly operating correctly on viewing the arterial trace on the patient monitor.

An error code was also displayed when troubleshooting - "IABP optical sensor calibration expired". Rezeroing was performed multiple times to try recalibrate the sensor, however this failed to resolve the issue. The fibre optic waveform was clearly not functioning correctly, so the decision was made to put the IAB into semi-auto mode and the radial arterial pressure was used to guide the patient treatment.

The balloon continued to inflate/deflate and function as expected. There were no issues regarding the patient and the decision was made to leave the catheter in situ and the assumption at the time was that the IABC sensor was failing and not the console itself. Treatment continued and the patient was unaffected.

Following this, during a weekly maintenance check the IABP was switched on and the alarm condition "AP optical sensing module failure maintenance required code #9" was displayed. The company was contacted and the console was removed from service.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Getinge CS300

ACTION TAKEN

The company proceeded with an initial repair of the optical sensor lamps within the optical sensor module. This however did not resolve the issue as the same issue was observed during a routine check.

The console has been removed from service and the suggestion is that the optical sensor module itself may need replacing.

RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

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