Page 12 - ANZCP GAZETTE DECEMBER 2023

PIRS REPORT
2023 Oxygenator (Gas transfer)
Permission to print: Category
Incident type Duration of incident: Description:
Yes
Oxygenator
Good Catch No Harm Incident hours
A Livanova Lilliput2 oxygenator for pediatric ECMO: failure to oxygenate
The first case was a 7y/o 17kg 111cm patient with VA-ECMO (post cardiac). Anti- coagulation was achieved with heparin and anti Xa of 0,3-0,6. We had a flow of 1 l/min with oxygenation problems. We attempted increased flows, however then the oxygenator was even less efficient hence we kept to 1l/min. The FiO2had to be put on 100% but pO2 was no higher than 9kPa post oxy measured by CDI and ABG. The sweep gas flow was 1,5l/min and HCT was 35%. The pre oxy PO2 was about 4,5-5kPa with CDI. We measure venous saturation and this was never lower than 55%. [We didn’t measure the pressure drop across the membrane]. After a 24h run we changed the oxygenator to see if another oxygenator would be more efficient, however this was not the case and we had the exact same gas transfer. After this run we contacted our local Livanova representative. While it was a borderline situation, the heart recovered sufficiently with pulmonary contribution, so that we felt that with the 100% FiO2 we could see it out. We thought initially it was a single incident, but the same problem occurred in another case. Another post cardiac VA ECMO (4.5kg and 57cm) we also had an oxygenator that did not oxygenate sufficiently where we only got 9kPa with 100% FiO2, blood flow was only 600ml/min. We managed to get an urgent delivery a different brand oxygenator as a standby, however, luckily after a few hours with this problem the LV function of the patient recovered enough so that there was enough cardiac output to deliver enough O2 so it did not justify an oxygenator change out at that moment. In both cases we placed the gas line on oxygen tank, to make sure it was not hospital pressure or a blender problem, without any effect. We returned a device with the same batch number than the oxygenators used as we could not save the oxygenator on first case due to patient which had MRSA.
GOOD CATCH - what went well Careful clinical judgement.
What could we do better Preventive actions
Type of incident: Hospital incident filed: Ext Authority Advised Discussed with team: Knowledge issue Protocol issue
Skill issue
Maybe preventively ordered different oxygenators after the first incident
Having different oxygenators on the shelf. We returned a system with the same batch number than the oxys used. However could not save the oxy on first case due to patient which had MRSA
Equipment No
Yes
No
No No No
Team Issue No Patient outcome variance f Nil
9 DECEMBER 2023 | www.anzcp.org