It was reported that during intra-aortic balloon (iab) therapy, the cardiosave intra-aortic balloon pump (iabp) unit alerted an autofill failure alarm.They tried to initiate autofill and received same failure.They attempted manual fill a few times, but it did not work.Customer called esp number on pump and spoke to answering service.While waiting for return call the staff ended up moving to impella after non successfully resolving pump issue.Customer reported not seeing any blood in pump but noted that inhouse biomed thought there was blood in the pump.Biomed noted that there was no blood in the pump but some blood on outside of pump.Getinge service tech was not called.A portage in-house biomed attended to pump.Patient died but customer noted they did not think this was a result of the balloon pump failure.The patient was not moved when the error occurred, however the patient did sit up while the iab was in place.The customer did not believe there was a kink because the iab pump was working without alarm initially, there was enough helium in the tank.Position of the iab was confirmed multiple times while patient was on the table with dr.(b)(6).The patient never made it off the table.Patient went into vfib (ventricular fibrillation) with multiple shocks, impella was then placed and patient went into pea (pulseless electrical activity) with multiple rounds of cpr, but patient expired.The status of the patient from the beginning was critical.The patient did make some improvement once iabp was placed and tvp (temporary transvenous pacing) was placed, but then the patient declined and continue to decline even after the impella was placed.This report is for the iab.A separate report has been submitted for the cardiosave iabp under mfg report number 2249723-2022-02917.
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