Description of Event or Problem · 0
PATIENT WAS SCHEDULED TO UNDERGO A CARDIAC CATH TO TREAT POSSIBLE CORONARY ARTERY DISEASE. AFTER ALL APPROPRIATE PROCEDURES WERE DONE TO PREPARE THE CONTRAST INJECTION DEVICE, THE PROVIDER INJECTED DYE INTO THE CORONARY ARTERIES VIA A RIGHT RADIAL CATHETER. THE TEAM MEMBER MONITORING THE PROCEDURE, WHO WAS RECORDING THE FLUOROSCOPY RECORDING NOTED WHAT APPEARED TO BE AIR IN THE LEFT ANTERIOR DESCENDING ARTERY (LAD) AND CIRCUMFLEX ARTERIES WITH WHAT APPEARED TO BE CARDIAC STANDSTILL. HE IMMEDIATELY ALERTED THE PROVIDER AND OTHER TEAM MEMBERS, AND EMERGENCY MEASURES WERE INITIATED. THE PATIENT WAS INTUBATED, AND CARDIAC MEDICATIONS WERE GIVEN. THE PROVIDER PLACED A SECOND LINE AND PROCEEDED TO PERFORM A PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) IN THE 100% OCCLUDED ARTERIES. THIS WAS SUCCESSFUL WITH REDUCING THE BLOCKAGE TO 0%. AN INTRA-AORTIC BALLOON PUMP (IAPB) WAS ALSO PLACED TO ASSIST WITH CARDIAC FUNCTION. HOWEVER, THEY WERE NOT ABLE TO GET CARDIAC FUNCTION TO RETURN ON ITS OWN. DESPITE ADVANCED CARDIAC LIFE SUPPORT (ACLS) MEASURES AND WORKING ON THE PATIENT FOR APPROXIMATELY 90 MINUTES, HE WAS DECLARED DEAD. INITIALLY, THE PROVIDER FELT THIS EVENT OCCURRED DUE TO A POSSIBLE "CLOT SHOWER" VS AIR EMBOLI. INVESTIGATION FROM OUR SIDE DID NOT IDENTIFY ISSUES WITH THE ACIST CVI INJECTOR DEVICE AS OUR BIOMED TECHNICIAN EXAMINED THE DEVICE. HOWEVER, WE COULD NOT RULE OUT ISSUES WITH THE OTHER PARTS OF THE SYSTEM INCLUDING THE TUBING, SYRINGE, OR MANIFOLD. THE DEVISE LOT NUMBERS ARE ASSUMED AS THESE ITEMS WERE IN THE SUPPLY AREA WHERE THIS EVENT OCCURRED. MANUFACTURER RESPONSE FOR CONTRAST INJECTION SYSTEM, ACIST CVI (PER SITE REPORTER). WAITING FOR THEIR REPORT.