PERFUSION REPORTS

REPORT
075
DATE
1/3/2021
TITLE
Electromagnetic interference with HLM
DETAILS OF INCIDENT

During an AVR with the cross clamp in situ a series of faults were noted on the S5 HLM. These included: 

Temporary failure of the 3 sucker roller pumps: "Sucker pump 3 fault" was displayed on the control panel-causing all 3 sucker roller pumps to reset. The screens turned off and rebooted. Once they rebooted they were fully functional again. This fault occurred twice during CPB.

Failure of cardioplegia calculator on data panel. "Cardioplegia pump 4a fault" was displayed on the control panel. The blood volume was not recorded on the cardioplegia data panel. We administered a 4:1 cardioplegia dose but had to calculate the cardioplegia volumes manually.

Defective arterial clamp: Following CPB, an error was displayed on the control panel

DETAILS OF INJURY TO PATIENT

There was no harm to the patient

TYPE OF DEVICE/MANUFACTURER

Liva Nova S5 HLM

ACTION TAKEN

The Liva Nova engineer was notified, they inspected the HLM machine and exported the data to send to the manufacturer. Initially the unit involved was not satisfied with the report genterated from Liva Nova (see below and attached) so waited for further instruction.

After receiving the report from Liva Nova, further actions were taken:

Ferrite blocks were put on the display/control panel, the CP5 centrifugal console and the arterial clamp. There were already ferrite blocks on the electronic gas blender of the machine affected.

The other S5 machines in the unit had ferrite blocks put on the display/control panel. There were already ferrite blocks on the electronic gas blenders.

RESPONSE FROM MANUFACTURER

see attached response

ADDTIONAL INFORMATION
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
083
1/6/21
IABP malfunction
REPORT NO
082
1/1/21
Accidental cardioplegia administration
REPORT NO
081
1/4/21
S5 Double Roller Pump incident
REPORT NO
080
1/5/21
Human factors issue
REPORT NO
079
1/6/21
Centrimag battery module failure
REPORT NO
078
1/6/21
Sampling manifold valve fault
REPORT NO
077
1/5/21
IABP transport issue
REPORT NO
076
1/4/21
Modified Ultrafiltration (MUF) Issue
REPORT NO
075
1/3/21
Electromagnetic interference with HLM
REPORT NO
074
1/2/21
HCU40 Failure
REPORT NO
073
1/2/21
HCU40 valve failures
REPORT NO
072
1/1/21
HCU40 failure
REPORT NO
071
1/1/21
LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD
REPORT NO
070
1/1/21
Loose component on circuit
REPORT NO
069
1/12/20
Centrifugal Head noise
REPORT NO
068
1/11/20
Venous Reservoir disposable issue
REPORT NO
067
1/11/20
Failure of Heater Cooler due to leaking valves
REPORT NO
066
1/11/20
Failure of Valves on heater cooler unit
REPORT NO
065
1/9/20
Intra Aortic Balloon Pump (IABP) Failure
REPORT NO
064
1/9/20
Centrifugal head failure
REPORT NO
063
1/8/20
Centrifugal head issue 4
REPORT NO
062
1/8/20
Human Factors Issue
REPORT NO
061
1/8/20
LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE
REPORT NO
060
1/8/20
Oxygenator Fibre Leak
REPORT NO
059
1/5/20
Failure to remove CO2 effectively
REPORT NO
058
1/7/20
Centrifugal Head Issue 3
REPORT NO
057
1/6/20
Centrifugal Head Issue 2
REPORT NO
056
1/1/20
Centrifugal Head Issue
REPORT NO
055
1/2/20
Faulty Pressure Relief Valves
REPORT NO
054
1/4/20
Leaking ALF
Perfusion Report cards are shown in batches of 30 at any one time where available.
115
114
111
110
109
108
107
106
105
104
103
102
101
100
099
098
097
096
095
094
093
092
091
090
089
088
087
086
085
084
083
082
081
080
079
078
077
076
075
074
073
072
071
070
069
068
067
066
065
064
063
062
061
060
059
058
057
056
055
054
053
052
051
050
049
048
047
046
045
044
043
042
041
040
039
038
037
036
035
034
033
032
031
030
029
028
027
026
025
024
023
022
021
020
019
018
017
016
015
014
London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.