Massive arterial air embolism during cardiopulmonary bypass: antegrade blood cardioplegia delivered by the pump — an accident waiting to happen

Abstract

Of the many possible causes of air embolism occurring in patients undergoing cardiopulmonary bypass (CPB), human error due to the perfusionist or the surgeon accounts for the vast majority. This case, however, presents a previously unreported, but recognized, cause of air embolism, due to a technical problem encountered during the administration of blood cardioplegia. The nature of some of the older CPB pumps allows the administration of cardioplegia at a time when the main CPB pump is not rotating. A situation may then arise whereby air may be entrained and delivered to the patient. The management of massive air embolism is discussed, and recommendations are made to prevent such an occurrence happening in the future.

Australasian perfusion incident survey

“…There were 24 gas-supply failures, comprising hospital supply failure (5), tubing disconnect (7), flow meter or blender failure (3), vaporizer problems (6) and other problems (3). Drug incidents included wrong drug (5), wrong dose (14), wrong fluid (1), wrong blood (1), allergy/anaphylaxis (10) and incorrect cardioplegia formulation (12).…”

“…Recent reports indicate that significant problems are still occurring, for example, complete electrical failure during CPB 11 or air embolus. 12 This study set out to examine the relative frequency in Australasia of critical incidents during CPB, the associated morbidity and mortality and the use of safety procedures to deal with them.…”

Successful Treatment of Accidental Air Embolism in Warm Heart Surgery

“…In spite of advances and refinements in CPB techniques and equipment, this complication continues to be reported in the literature. 1…”