Electrical failure during cardiopulmonary bypass: an evaluation of incidence, causes, management and guidelines for preventative measures

Cardiopulmonary Bypass Emergencies and Intraoperative Issues

Cardiopulmonary bypass (CPB) is a complex biomechanical engineering undertaking and an essential component of cardiac surgery. However, similar to all complex bioengineering systems, CPB activities are prone to a variety of safety and biomechanical issues. In this narrative review article, the authors discuss the preventative and intraoperative management strategies for a number of intraoperative CPB emergencies, including cannulation complications (dissection, malposition, gas embolism), CPB equipment issues (heater-cooler failure, oxygenator issues, electrical failure, and tubing rupture), CPB circuit thrombosis, medication issues, awareness during CPB, and CPB issues during transcatheter aortic valve replacement.

Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration

OBJECTIVES

The frequency and impact of power failure on surgical care over time in a large integrated healthcare system such as the Veterans Health Administration (VHA) is unknown. Reducing the likelihood of harm related to these rare but potential catastrophic events is imperative to ensuring patient safety and high-quality surgical care. This study provides analysis and description of reported power failures during surgery (January 2000-March 2019), in the VHA and their impact.

METHODS

This quality improvement study describes patient safety adverse events related to power failure in the operating room reported by 63 VHA medical centers from the approximately 137 VHAs with a surgical program. Power failure events during surgery reported to the VHA National Center for Patient Safety are analyzed.

RESULTS

The authors identify 20 root cause analyses and 135 safety reports. Most events 36.1% (n = 56) resulted from generator delay, equipment reboot delay 21.9% (n = 34), and equipment backup power failure 13.5% (n = 21). Root causes include issues with backup batteries or equipment, engineering and clinical staff communication, standardized procedures for testing power, backup power delay, electrical circuit issues, documentation, and training. Patient harm occurred in 18% (n = 28) and 3.9% (n = 6) as major or catastrophic.

CONCLUSIONS

Power failure during surgery is associated with major or catastrophic patient harm, though rare. Staff preoccupation with failure, disaster preparedness, and focus on communication has the potential to minimize or avoid patient harm.

Electrical failure during cardiopulmonary bypass: a critical moment

Electrical failure during cardiopulmonary bypass is a crisis situation for the cardiac surgical team. Fortunately, it has a low incidence with low morbidity and mortality rates. Notwithstanding, institutional preventative and management measures should be taken. Here, we report a case of electrical failure during cardiopulmonary bypass, which was successfully managed during the surgery, allowing the patient to recover uneventfully. These unwanted complications can only be managed by promoting awareness and putting in place strategies against them.

Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah’s witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid–base alterations.

Crisis in the operating room: fires, explosions and electrical accidents

Fires, explosions and electrical accidents in the operating theater are rare events, but are devastating in terms of structural damage to the equipment in theaters and to human lives. While various circumstances lead to these troubles, we can avoid and manage them by learning from the instructive cases accumulated so far. We describe operating room crises such as fires, explosions and electrical breakdowns, and discuss causes and countermeasures.

Case reports: response to a partial power failure in the operating room

Failure of the power supply to the operating suites is a rare event. When it happens, it is critical that the care team responds in a way that optimizes patient safety. In the event we describe in this case report, only the emergency (red) power outlets failed. The anesthesia care team and other staff in the 8 affected rooms with anesthetized patients generally responded appropriately. The optimal response to these events is not necessarily intuitive. It is important to have advanced planning both within the immediate work area and beyond the operating room all the way into the hospital infrastructure.

Quantitative evaluation of hand cranking a roller pump in a crisis management drill

The heart-lung machines for open-heart surgery have improved over the past 50 years; they rarely break down and are almost always equipped with backup batteries. The hand-cranking procedure only becomes necessary when a pump breaks down during perfusion or after the batteries have run out. In this study, the performance of hand cranking a roller pump was quantitatively assessed by an objective method using the ECCSIM-Lite educational simulator system. A roller pump connected to an extracorporeal circuit with an oxygenator and with gravity venous drainage was used. A flow sensor unit consisting of electromagnetic sensors was used to measure arterial and venous flow rates, and a built-in pressure sensor was used to measure the water level in the reservoir. A preliminary study of continuous cranking by a team of six people was conducted as a surprise drill. This system was then used at a perfusion seminar. At the seminar, 1-min hand-cranking drills were conducted by volunteers according to a prepared scenario. The data were calculated on site and trend graphs of individual performances were given to the participants as a handout. Preliminary studies showed that each person's performance was different. Results from 1-min drills showed that good performance was not related to the number of clinical cases experienced, years of practice, or experience in hand cranking. Hand cranking to maintain the target flow rate could be achieved without practice; however, manipulating the venous return clamp requires practice. While the necessity of performing hand cranking during perfusion due to pump failure is rare, we believe that it is beneficial for perfusionists and patients to include hand-cranking practice in periodic extracorporeal circulation crisis management drills because a drill allows perfusionists to mentally rehearse the procedures should such a crisis occur.

Blackout of 2003: public health effects and emergency response

We examined the public health effects of the Northeast blackout of August 2003 and the emergency response to the blackout by the New York City Department of Health and Mental Hygiene (DOHMH). We reviewed departmental documents from the DOHMH Emergency Operations Center and surveyed DOHMH employees to identify deficiencies in the response and elicit suggestions for improvement. DOHMH deployed its all-hazards, scalable public health Incident Management System to respond to several impacts: (1) failure of multiple hospital emergency generators; (2) patients dependent on electrically powered equipment; (3) loss of electronic data input to the DOHMH syndromic surveillance system from hospital emergency departments; (4) potential for vaccine spoilage due to loss of refrigeration; (5) beach contamination with untreated sewage; (6) heat-related health effects and increase of foodborne disease; and (7) potential for an increased rodent population as a result of increased amounts of discarded perishables. Areas identified for improvement included communications during the event, DOHMH dependence on an external source of electricity, facility management during the response, and lack of readily available and appropriate emergency supplies.