It was reported that during use of the device for a cardiopulmonary bypass (cpb) procedure, the level sensor pads were coming off and triggered the level detector alarm.As a result, an alternate device was employed.The surgical procedure was completed successfully.There was no delay, no blood loss, nor adverse consequences to the patient.Per clinical review: the perfusionist does not have an exact date of occurrence with the level sensor pads popping off the reservoir, but has stated that in the last seven months this issue has occurred about once every three weeks.The team has their system set up to just use the red alarm level sensor pad and cable, and it is set up to just alert the perfusionist, not to intervene to stop the roller pump.This issue has occurred on both the rx05 and rx15 oxygenator.She does state that she puts the level sensor pad on the graduated label on the front of the reservoir, and we have discussed the need to put it on a non-label area on the reservoir.According to the information available, she has waited the five minutes to attach the sensor cable, prior to bypass, but when she is on bypass and the level sensor pad disconnects from the reservoir, there is an urgent need to re-attach it or adhere a new one, so the five minutes is not feasible.This incident did not delay the continuation of the surgical procedure.There was no blood loss or harm associated with the event.
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