PERFUSION REPORTS

REPORT

140

DATE

12/6/2026

TITLE

Isoflurane vaporiser

DETAILS OF INCIDENT

Incident date 20/12/2023. Midway through procedure, Isoflurane turned on to treat hypertension. Isoflurane bracket was resting on a sidebar of the HLM. This upward lift broke the seal in the isoflurane, completely cutting gas supply to the oxygenator.

DETAILS OF INJURY TO PATIENT

Patient died post up due to complications.

TYPE OF DEVICE/MANUFACTURER

Datex Ohmeda

ACTION TAKEN

In-line monitoring picked up the problem and raised multiple alarms. 2nd perfusionist came to help. As no clear problem with gas flow due to ball in Sechrist blender floating normally and gas line appeared intact, the decision was made by perfusionist 2, to change oxygenator. Perfusionist 3 came to help with change-out. On recommencing bypass, hypoxia remained, at which point perfusionist 4 removed the vaporiser from the bracket and the issue resolved.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

Full Patient Level Safety Report was carried out. On investigation, nothing was found to be wrong with the vaporiser or the bracket.

This is a design fault with the bracket made by G.A.S (General Anaesthetic Services). I understand this does not have CE marking as I have tried to buy replacements, but cannot do so. MHRA not contacted as there was no fault found.

Presented this case at the safety committee session at the annual congress in Nottingham 2025.

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SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

110



31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

Detached bullet tip of sump-updated response Sep 2022

REPORT NO

092



1/10/21

Vapourizer Issue

REPORT NO

091



1/10/21

Oyxgenator Leak

REPORT NO

090



1/10/21

Breach of chemical cleaner

REPORT NO

089



1/9/21

Sechrist Gas Blender Sweep on ECMO

REPORT NO

088



1/9/21

Oxygenator High Pressure Events

REPORT NO

087



1/10/21

Leaking one way valve

REPORT NO

086



1/7/21

Electronic Gas Blender Fault

REPORT NO

085



1/2/21

Protamine Administration Issue

REPORT NO

084



1/6/21

Damaged roller pump lid

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

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