A retrospective study on perfusion incidents and safety devices

Despite the acceptance of extracorporeal circulation as an effective modali ty to facilitate cardiac surgery patient outcomes can be negatively influen ced by the occurrence of perfusion incidents. A perfusion survey was conduc ted to identify safety techniques and incidents related to cardiopulmonary bypass (CPB). An 80-question survey was mailed to chief perfusionists of ail 1030 USA car diac surgical centers using CPB. The survey was designed to examine practic es and incidents that occurred during a 2-year period (July 1996 to July 19 98). Five-hundred-and-fifty-two (54% response rate) surveys were returned, which accounted for 797 hospitals (79% of all cardiac centers) and 653 621 surgical procedures. Of the 27 identified CPB safety devices, the highest u tilization was arterial line filters (98.5%) and the lowest arterial line b ubble traps (3.4%). Of the reported cases, a CPB incident occurred once eve ry 138 cases. The most common occurring incidents were protamine reactions( 1:783), coagulation problems (1:771), and heater/cooler failures (1.1809). The rate of occurrence of an incident resulting in a serious injury or deat h was one for every 1453 procedures. Although techniques and safety devices create a relatively secure environme nt for CPB, lower incident rates may be achieved with further improvements in coagulation monitoring and incident reporting.