PERFUSION REPORTS

REPORT

138

DATE

20/4/2026

TITLE

Oxygenator Changeout

DETAILS OF INCIDENT

Oxygenator changeout performed during Type A Aortic Dissection repair due to high pre membrane pressure and low post membrane pressure - 300 mmHg difference. Fine going on bypass but 20 minutes in could no longer run at full flow and could only flow at 75% flow. Asked surgeon to cool to 22C so we could perform oxygenator changeout. Temperature and gas management were all okay. Changeout performed in under 2 mins went back to full flow to ensure new oxygenator was working and pressures were much better before then performing DHCA and antegrade cerebral perfusion & continuing with the operation. No harm occurred.

DETAILS OF INJURY TO PATIENT

No harm

TYPE OF DEVICE/MANUFACTURER

LivaNova Inspire 8 oxygenator. Product code IN00664. Lot/Batch No 2601150031. Date of manufacture 17/04/2026, Expiry date 14/01/2029.

ACTION TAKEN

Oxygenator changeout

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

No issue was logged with the manufacturer as they believe it may have been a patient specific issue during initial cooling. Exact cause has not been established.

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
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

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

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071



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

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

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

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

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065



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064

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REPORT NO

063



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REPORT NO

062



1/8/20

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REPORT NO

061



1/8/20

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REPORT NO

060



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REPORT NO

059



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REPORT NO

058



1/7/20

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057



1/6/20

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REPORT NO

056

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055



1/2/20

Faulty Pressure Relief Valves

REPORT NO

054



1/4/20

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REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



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REPORT NO

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

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