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Chapter 20 - Common and Uncommon Disasters during Cardiopulmonary Bypass

Published online by Cambridge University Press:  24 October 2022

Florian Falter
Affiliation:
Royal Papworth Hospital, Cambridge
Albert C. Perrino, Jr
Affiliation:
Yale University Medical Center, Connecticut
Robert A. Baker
Affiliation:
Flinders Medical Centre, Adelaide
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Summary

Cardiopulmonary bypass (CPB) is highly technical and complex and accident and error can occur due to malfunction of equipment and/or human factors.Since its first successful clinical use in 1953, incremental improvements in the heart lung machine have resulted in a decline of perfusion related accidents. Safety practices have been demonstrated to reduce the incidence of error and equipment fault and need to be constantly reviewed and their implementation should be regularly rehearsed by all members of the intraoperative team and not only by the perfusion team. Institutional protocols, compliance with instructions for use of equipment and step-by-step processes to deal with error and unforeseen events will minimize their impact.

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Publisher: Cambridge University Press
Print publication year: 2022

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References

Suggested Further Reading

Reason, J. Human error: models and management. BMJ. 2000; 320 (7237):768770.CrossRefGoogle ScholarPubMed
Wilcox, TW, Baker, RA. Incident reporting in perfusion: current perceptions on PIRS-2. J Extracorp Tech 2020; 52:712.CrossRefGoogle Scholar
Darling, E, Searles, B. Oxygenator change-out times: the value of a written protocol and practice simulation exercises. Perfusion 2010 May; 25(3):141143; discussion 144–145.CrossRefGoogle ScholarPubMed
Uysal, S, Lin, HM, Trinh, M et al. Optimizing cerebral oxygenation in cardiac surgery: a randomized controlled trial examining neurocognitive and perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159(3):943953.e3CrossRefGoogle ScholarPubMed
Ferraris, VA, Brown, JR, Despotis, GJ et al. Special report: STS workforce on evidence based surgery. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines * The Society of Thoracic Surgeons Blood Conservat. ATS. 2011;91(3):944982.Google Scholar
Shore-lesserson, L, Baker, RA et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists and The American Society of ExtraCorporeal Technology: Clinical practice guidelines – anticoagulation during cardiopulmonary bypass. Ann Thorac Surg. 2018;105(2):650662.Google Scholar
Gulabani, M, Gurha, P, Ahmad, S et al. Intra-operative post-induction hyperthermia, possibly malignant hyperthermia: anesthetic implications, challenges and management. J Anaesthesiol Clin Pharmacol. 2014;30(4):555557.Google Scholar
Still, RJ, Hilgenberg, AD, Akins, CW et al. Intraoperative aortic dissection. Ann Thorac Surg. 1992;53(3):374379.Google Scholar
Assaad, S, Geirsson, A, Rousou, L et al. The dual modality use of epiaortic ultrasound and transesophageal echocardiography in the diagnosis of intraoperative iatrogenic type-a aortic dissection. J Cardiothorac Vasc Anesth. 2013 Apr;27(2):326328.CrossRefGoogle ScholarPubMed

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