Page 15 - ANZCP Gazette-August-Booklet

Incident # Incident #3
Incident type
Good catch, no harm incident
Type of incident:
Management
Category
Drug / Medication
Description:
Overnight set up with a 4:1 cardioplegia system was used to do a case with del Nido cardioplegia. del Nido cardioplegia was made and hung onto the pump. The pump was deaired and wheeled into the operating room. Checklist was completed and lines were divided. Patient was put on
bypass. Cardioplegia was started and arrest was attained with 400 mL given – a quick glance was made to see if all was looking OK. However it
was discovered that the cardioplegia tubing was not switched for 1:4 delivery. Immediately the surgeon was informed and help was obtained from coordinator to switch the tubing to complete delivery of del Nido cardioplegia. Cardioplegia
was stopped, tubing was switched, the arterial pump was stopped and the pump was recirculated to remove any GME for a minute or so. Once satisfied, the main pump was restarted and then cardioplegia was delivered with the case continuing as planned.
What went well
A thorough check of pump and tubings after X-clamp.
Help from supervisor ( n plus 1)
Clear communication between surgeon and perfusion.
Future preventive actions
Adapted the checklist for a specific del Nido tubing check
What could we do better
A proper checklist specifically for del Nido, or a checklist that indicated if tubing was switched.
Incident type
Good catch, no harm incident
Type of incident:
Management
Category
Gas Supply
Description:
The procedure was an AVR. Blood pCO2 levels escalated. Was unable to decrease pCO2 levels despite increasing sweep and decreasing the CO2 [operative field] insuflation.
Initially we went onto full flows and noticed a high CO2; even after calibrating [the Spectrum M4] after a blood gas. The pCO2 was 5.56 kPa [41.7 mmHg] preoperatively; and around 6.8k Pa [51 mmHg] near the start of initiating bypass. It further increased to around 8 Kpa [60 mmHg] as the case went on, although there seemed to be a slight decrease initially as we increased the sweep gas to bring down the CO2.
What went well
Good communication with anaesthesia.
We traced the gas pathway to find that the capnograph line was trapped underneath the isofluorane vaporizer.
Future preventive actions
An addition has been made to the checklist – vaporizer seated correctly
The capnograph line is secured away from the vaporizer
What could we do better
Isofluorane vaporizer position check and positioned properly after refilling
SEPTEMBER 2020 | www.anzcp.org 12