PERFUSION REPORTS

REPORT

135

DATE

3/2/2026

TITLE

Human Factors

DETAILS OF INCIDENT

During an elective AVR for severe AS, a locum perfusionist was supervising our trainee perfusionist. Bypass was initiated, root vent cannula was placed, and the cross clamp was applied. Cardioplegia delivery was initiated antegradely with cold oxygenated blood cardioplegia. The heart was not arresting, therefore, the aorta was opened and cold oxygenated blood cardioplegia was delivered down the ostia.

DETAILS OF INJURY TO PATIENT

No harm to patient.

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

Help was called (2nd perfusionist) to investigate as the locum perfusionist was concerned that the cardioplegia was not effective. After 6 minutes and a total of 1L cold oxygenated cardioplegia the 2nd perfusionist checked the circuit and noticed that the circuit was patent and air free, however, the white clip for the cardioplegia infusion was closed off, therefore the previous delivery had been of cold oxygenated blood only. The clip was subsequently opened and 1L of cold blood cardioplegia was delivered down the ostia and the heart was successfully arrested.

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The surgeon and anaesthetist were immediately informed during the fault finding and the issue was resolved. An ABG was done after cardioplegia delivery which confirmed expected normal ABG values for CPB. The rest of the case was uneventful, when the clamp was removed the heart restarted without issue and the ABGs were all as expected.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

‍Staffing did not allow for the senior perfusionist on duty to supervise the trainee as they would normally, as 2 other members of staff were off. The senior perfusionist was on call and would be doing the second case. The staff perfusionist cannot supervise trainees due to departmental educational rules. Therefore, the locum perfusionist (+20 years of experience) was deemed appropriate to supervise the trainee. As a team, there could have perhaps been a second check of the pump since the locum perfusionist is new to the department.

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OUTCOME ACTIONS:

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Review of pre CPB checklist to perhaps include 'cardioplegia clip opened' or completely remove the white clip from the circuit design.
Perhaps new practice rule i.e. new locum perfusionists not to supervise trainees unless they have been here more than once.
2 person pre CPB checklist for locum staff or new staff

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