DATE
09-2015
FSN
020
TITLE
Potential Mycobacterial Contamination Of HCUs
PROBLEM

Safety Advisory

The joint Perfusion bodies and their Safety Committee (SC) are fully aware of the recent circumstances and situation surrounding the potential Mycobacterial contamination of heater/cooler units and the possible but unconfirmed link to endocarditis and other surgical site infections.

We are working closely with the relevant organisations involved in this investigative process including Public Health England (PHE), NHS England, MHRA, DH, SCTS and ACTA. PHE is coordinating the national response. PHE are currently looking at de-escalating the issue with a timeline consistent according to the final round of testing on some of the latest devices. By de-escalation, PHE are referring to some final guidance that will be available to all parties concerned that should be used by departments to develop a strategy plan. We recommend that all departments familiarise themselves will all the current guidance available via the links to the documents below and that you liaise closely with your local infection control team on this matter.

Should you or your department wish to discuss this issue further or have any queries concerning these documents, the safety committee ( safetycommittee@scps.org.uk ) are willing to be of assistance, but we also need to remind you that the most up to date information will always be held by PHE.

FIELD SAFETY NOTICES (FSN)

London Core Review Cardiothoracic Surgery Course - Touch icon
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REPORT NO
021
DATE
03-2017
Infections Associated With HCUs In CPB & ECMO
REPORT NO
020
DATE
09-2015
Potential Mycobacterial Contamination Of HCUs
REPORT NO
019
DATE
02-2014
SWISSMEDIC: Water-Borne Infection In Implant Patients
REPORT NO
018
DATE
01-2014
Maquet Cardioplegia Temperature Reading Inaccuracies
REPORT NO
017
DATE
02-2013
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
016
DATE
01-2013
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
015
DATE
03-2012
Sucker Placed In Raceway In Wrong Direction
REPORT NO
014
DATE
02-2012
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
013
DATE
01-2012
Maquet Adhesive Failure On Oxygenator Blood Outlet Connector
REPORT NO
012
DATE
08-2011
Sorin Heat Exchanger Blood Water Leak
REPORT NO
011
DATE
07-2011
Aorta Remained Clamped Post CPB
REPORT NO
010
DATE
06-2011
Maquet Transient Increase In Pump Speeds
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