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The perfusionist reported he noticed the 8" roller head on the heart lung machine losing occlusion at the end of the case.The flow probe was reading ~1l different than the calculated flow.The perfusionist made sure all of the shunts were closed.After the case, he checked occlusions again and found one roller was off by 10 clicks and the other was off by 12 clicks.He replaced this roller with a backup roller.Manufacturer response for roller pump, quantum perfusion system (per site reporter).Company identified that at high rpm (>190), occlusion locking mechanism can shift after a hard stop (lid open and safeties).Company replicated this issue in other 8" roller pumps.Company noted the exact rpm varies by pump, but is consistently 180 rpm or higher.Company states it will assess system adjustments to mitigate this issue.
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