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Cracked and fragmented connector after spillage of isoflurane.
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Cardiopulmonary bypass (CPB) is widely used for cardiac surgery by virtue of its proven safety over the course of its use during the past half century. Even though perfusion is safer, incidents still occur. During the repair of a ventricular-septal defect in an 11-month-old infant, we experienced a critical incident related to the potential hazardo...
Context in source publication
Context 1
... was traced to the initiation of CPB, when the vaporizer (PPV, Penlon, UK) connected to the membrane oxygenator was filled with isoflurane and droplets of isoflurane fell onto the connector. A test was carried out by dropping a small amount of isoflurane on a different connector made from the same material and it was observed to deteriorate (Fig. 1). After this incident, the isoflurane vaporizer was then moved to a safer location to prevent a similar incident from occurring ...
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Ventricular septal defect (VSD) is the most common congenital heart defect at birth but is relatively rare in adult population. Apart from congenital, VSD may also be acquired. It can be caused by trauma, myocardial infarction or previous cardiac surgeries such as valvular replacements or VSD closure attempts. Surgical closure of VSD remains the tr...
Citations
... During CPB, volatile anesthetics are generally administered through the oxygen inlet line using an anesthetic vaporizer to augment the level of sedation and control the blood pressure. However, volatile anesthetics are known to have an adverse physicochemical effect on polycarbonates (2). There are reports of damaged plastic anesthetic equipment and other medical devices (3)(4)(5)(6)(7), particularly, damaged CPB parts made from polycarbonate, such as membrane oxygenators (6,7). ...
Mishaps, near misses, and lethal incidents are known to occur during cardiopulmonary bypass. We share one such rare case of break in polycarbonate connector because of the use of isoflurane in extracorporeal circuit and its successful management.
... 158 Case reports also describe severe damage to the plastic components of the circuit by spillage of liquid volatile anesthetic ( Fig. 8; video supplied on request). [159][160][161][162] Figure 9 demonstrates insertion of a vaporizer on a contemporary CPB machine well away from the plastic CPB components in an effort to reduce this potential hazard. However, there are no specific instructions from device manufacturers ensuring that vaporizers are placed in a safe position. ...
Cardiopulmonary bypass (CPB) required for cardiac surgery presents unique challenges to the cardiac anesthesiologist responsible for providing the 3 most basic facets of any anesthetic: amnesia, analgesia, and muscle relaxation. Unique pathophysiologic changes during CPB result in pharmacokinetic alterations that impact the serum and tissue concentrations of IV and volatile anesthetics. Similarly, CPB causes pharmacodynamic alterations that impact anesthetic efficacy. The clinical significance of these alterations represents a "moving target" as practice evolves and the technology of CPB circuitry advances. In addition, perfusionists choose, modify, and maintain the CPB circuitry and membrane oxygenator. Thus, their significance may not be fully appreciated by the anesthesiologist. These issues have a profound impact on the anesthetic state of the patient. The delivery and maintenance of anesthesia during CPB present unique challenges. The perfusionist may be directly responsible for the delivery of anesthetic during CPB, a situation unique to the cardiac suite. In addition, monitors of anesthetic depth-assessment of clinical signs, hemodynamic indicators, the bispectral index monitor, end-tidal anesthetic concentration, or twitch monitoring-are often absent, unreliable, or directly impacted by the unique pathophysiology associated with CPB. The magnitude of these challenges is reflected in the higher incidence of intraoperative awareness during cardiac surgery. Further complicating matters are the lack of specific clinical guidelines and varying international policies regarding medical device specifications that add further layers of complexity and introduce practice variability both within institutions and among nations. We performed a systematic survey of the literature to identify where anesthetic practice during CPB is evidence based (or not), identify gaps in the literature to guide future investigations, and explore the implications of evolving surgical practice, perfusion techniques, and national policies that impact amnesia, analgesia, and muscle relaxation during CPB.
... Spillage of isoflurane onto the oxygenator causes cracking of the polycarbonate casing, so it is essential to position the vaporiser away from the oxygenator. 10 Removing the vaporiser from the CPB machine before filling with the anaesthetic agent eliminates the risk of damage resulting from potential spillages. ...
Since its inception, administering and ensuring anaesthesia during cardiopulmonary bypass has been challenging. Partly because of the difficulty of administering volatile agents during cardiopulmonary bypass, total intravenous anaesthesia has been a popular technique used by cardiac anaesthetists in the last two decades. However, the possibility that volatile agents reduce mortality and the incidence of myocardial infarction by preconditioning the myocardium has stimulated a resurgence of interest in their use for cardiac anaesthesia. The aim of this review is to provide an overview of the administration of volatile anaesthetic agents during cardiopulmonary bypass for the maintenance of anaesthesia and to address some of the practical issues that are involved in doing so.
... In addition to the foreseen physiologic changes with the use of ECC, complications from equipment malfunction have been reported [2][3][4] . Failures of the EEC equipment may be related to circulation pumps (electrical or mechanical failures) and with oxygenators and circuits (cracks, disconnections, embolism, hemolysis, obstruction of blood or gas flow, defect or leakage of the heat-exchanger, and defect on the gas blender). ...
... Além das alterações fisiológicas previstas com a utilização da CEC, relatos de complicações pelo mau funcionamento do dispositivo foram descritos [2][3][4] . As falhas do aparelho de CEC podem ser relacionadas com as bombas de circulação (falhas elétricas ou mecânicas) e com os oxigenadores e circuitos (rachaduras, desconexões, embolia, hemólise, obstruções do fluxo sanguíneo ou gasoso, defeito ou vazamento no permutador de calor, defeito no misturador de gases). ...
The introduction of extracorporeal circulation in clinical practice was decisive for the development of modern cardiovascular surgery. Addition of new procedures and equipment, however, brings inherent risks and complications. The objective of this report is to describe a malfunction of the oxygenation system and emphasize the importance of the interaction among the medical team members to prevent errors and complications.
During valve replacement and IVC correction surgery, we observed a darker shade of red in the blood on the exit of the oxygenator. Laboratory tests demonstrated severe acidosis and hypoxemia. The entire system was evaluated, but the cause of the malfunction was not found. Measures to reduce damage were successfully instituted. After the surgery, the whole system underwent technical evaluation.
Interaction among the medical team members, early diagnosis, and immediate intervention were fundamental for a favorable outcome.
The MYRIAD trial demonstrated that cardiac surgery with either volatile anesthesia or intravenous anesthesia techniques can be comparable with respect to morbidity and mortality. Maintaining anesthesia during cardiopulmonary bypass with either approach requires appreciation of the nuances that are unique to each. This narrative review addresses these technical challenges and other considerations.
Protection of myocardium from ischemic and reperfusion lesions continues to be an important issue in the modern cardiac surgery. Russian and foreign publications contain a significant number of data about the protective impact of pre- and post-conditioning with inhalation anesthetics (sevoflurane, isoflurane, and desflurane) on the myocardium. The article highlights that this protective action is maximum when these drugs are used during the whole operation and it means during cardiopulmonary bypass as well. Therefore, currently, the listed above inhalation anesthetics are used fairly frequent during cardiopulmonary bypass. However, the technology of inhalation anesthesia during perfusion has a number of specific features: changes in the pharmacokinetics of drugs (which provides impact on the dosing of anesthetics), design of oxygenator, which plays a certain role when the anesthetics are supplied to the blood, monitoring during inhalation anesthesia, technical assistance for this technology and important safety issues. This review describes the above-mentioned aspects.
The review is devoted to one of the most critical issues of modern intensive care – the diagnostics of sepsis in children. The article describes the modern definition of sepsis and presents the review of the recent publications devoted to pediatric sepsis. It speculates on the benefits and drawbacks of Sepsis-3 recommendations for pediatric intensive care. The special emphasis is put on the early detection and assessment of organ failure severity in the children with an infection using special scores of qSOFA or PELOD-2.
Anesthetic management during cardiopulmonary bypass (CPB) is challenging in many aspects. Evidence of mortality reduction due to the use of volatile agents during cardiac surgery has led to their increased use in CPB. Partly because of the difficulty to administer volatile agents during CPB, total intravenous anesthesia (TIVA) has become the most popular technique used by cardiac anesthetists throughout this critical period. The aim of this review is to provide an overview of volatile agents’ administration to ensure maintenance of adequate depth of anesthesia during CPB and weighting risks and benefits of this technique compared to TIVA.
JUSTIFICATIVA E OBJETIVOS: A introdução da circulação extracorpórea (CEC) na prática clínica foi decisiva para o desenvolvimento da cirurgia cardiovascular moderna. A adição de novos procedimentos e equipamentos, entretanto, traz riscos e complicações inerentes. O objetivo deste relato é descrever um caso de mau funcionamento do sistema de oxigenação e enfatizar a importância da interação entre a equipe médica para prevenir erros e reduzir complicações. RELATO DO CASO: Durante a realização de cirurgia para troca valvar e correção de CIV, observou-se coloração escura do sangue na saída do oxigenador. Exames laboratoriais demonstraram acidose e hipoxemia grave. Todo o sistema foi reavaliado, mas a causa do mau funcionamento não foi encontrada. Medidas para a redução do dano foram instituídas com sucesso. Após a cirurgia, todo o sistema de CEC foi submetido à avaliação técnica. CONCLUSÕES: A interação entre a equipe, o diagnóstico precoce e a intervenção imediata mostraram-se fundamentais para o desfecho favorável.
