Unexplained obstruction of an integrated cardiotomy filter during cardiopulmonary bypass

Cory M. Alwardt, Donald S. Wilson, Octavio E. Pajaro

Research output: Contribution to journalArticle

Abstract

Cardiopulmonary bypass (CPB) is considered relatively safe in most cases, yet is not complication free. We present a case of an integrated cardiotomy filter obstruction during CPB, requiring circuit reconfiguration. Approximately an hour after uneventful initiation of CPB the integrated cardiotomy filter became obstructed over several minutes, requiring circuit reconfiguration using an external cardiotomy filter to maintain functionality. Following reconfiguration, CPB was maintained with a fully functional circuit allowing safe patient support throughout the remainder of CPB. Postoperatively, there was no sign of thrombus or mechanical obstruction of the filter, which was sent to the manufacturer for analysis. The cause of the obstruction was unclear even after chemical analysis, visual inspection, and a review of all techniques and products to which the patient was exposed. The patient had a generally routine hospital stay, with no signs or symptoms related to the incident. To our knowledge, this is the first report describing an obstructed integrated cardiotomy filter. An appropriate readiness plan for such an incident includes proper venting of the filter chamber, a method for detecting an obstruction, and a plan for circuit reconfiguration. This case illustrates the need for a formal reporting structure for incidents or "near miss" incidents during CPB.

Original languageEnglish (US)
Pages (from-to)59-63
Number of pages5
JournalJournal of Extra-Corporeal Technology
Volume49
Issue number1
StatePublished - 2017

Fingerprint

Cardiopulmonary Bypass
Risk Management
Signs and Symptoms
Length of Stay
Thrombosis

Keywords

  • Cardiopulmonary bypass
  • Cardiotomy
  • CPB
  • Filter
  • Obstruction

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Unexplained obstruction of an integrated cardiotomy filter during cardiopulmonary bypass. / Alwardt, Cory M.; Wilson, Donald S.; Pajaro, Octavio E.

In: Journal of Extra-Corporeal Technology, Vol. 49, No. 1, 2017, p. 59-63.

Research output: Contribution to journalArticle

Alwardt, Cory M. ; Wilson, Donald S. ; Pajaro, Octavio E. / Unexplained obstruction of an integrated cardiotomy filter during cardiopulmonary bypass. In: Journal of Extra-Corporeal Technology. 2017 ; Vol. 49, No. 1. pp. 59-63.
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