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

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