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

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048

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043



1/7/19

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042

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1/2/19

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1/2/19

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038

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037

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1/10/17

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036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

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REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

REPORT NO

032



Sucker Placed In Raceway In Wrong Direction

REPORT NO

031



High Transmembrane Pressure Gradients

REPORT NO

030



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REPORT NO

029



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REPORT NO

028



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REPORT NO

027



Paragon Oxygenator Gas Inlet Leak

REPORT NO

026



Maquet IABP Console Failure

REPORT NO

025



Sorin EOS Gas To Blood Leak Whilst Priming

REPORT NO

024



Chalice Paragon Midi Heat Exchanger Leak Whilst Priming

REPORT NO

023



Chalice Paragon Heat Exchanger Water To Blood Leak

REPORT NO

022



Vent Pump Boot Tubing Inserted In Wrong Way Round

REPORT NO

021



Paragon Oxygenator Heat Exchanger Leak

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