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
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080



1/5/21

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079



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078



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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

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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

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

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