Description of Event or Problem · 0
UPON DAILY CHARGE CHECKS, ECMO (EXTRACORPOREAL MEMBRANE OXYGENATION) SPECIALIST WAS CHECKING THE FRESENIUS NOVALUNG IN THE CARDIAC CATH LAB ENSURING IT WAS READY TO BE USED IN EMERGENCY. UPON START UP THE P2 PRESSURE SENSOR WAS NOT LIT UP INDICATING THE CABLE WASN'T CONNECTED. THE CABLE WAS UNPLUGGED AND PLUGGED BACK INTO THE PRESSURE SENSOR AND BOX, WHICH DID NOT FIX THE ISSUE, IF THE CORD WAS WIGGLED AT THE PRESSURE SENSOR SITE THE P2 WOULD POP UP MOMENTARILY, BUT THEN POP OFF AGAIN. CABLE WAS EXCHANGED WITH ANOTHER PRESSURE CABLE AND SEEM TO REMEDY THE SITUATION. STOPPED INSULIN, DISCONNECTED PUMP TUBING FROM BODY. 4:04AM CGM 136 (TWO UP ARROWS). RECONNECTED TUBING (ODDLY, FELT A DROP OF INSULIN AT CONNECTION POINT), RESTARTED INSULIN, BUT TURNED OFF CONTROL IQ BECAUSE IT WANTED TO GIVE MORE THAN 3X BASAL RATE (.988 RATHER THAN .3) AND I WAS AFRAID OF MORE HYPOGLYCEMIA. 5:09AM CGM 88, HAD 26G (GRAPE JUICE, CHOCOLATE). STOPPED INSULIN, DISCONNECTED FROM BODY. 5:20AM FILLED NEW CARTRIDGE, RESTARTED CONTROL IQ, PROBLEMS RESOLVED 7:20 CGM 88, IN SPITE OF EATING 133G OF CARBS BETWEEN 8PM AND 5:10AM (NORMALLY I EAT 30-35G IN 24 HOURS), BLOOD SUGAR NEVER ROSE ABOVE 136 BEFORE MORNING. GIVEN EVERYTHING I HAVE NOTED HERE, I AM CONVINCED (AND MY DOCTOR AGREES) THAT A FAULTY CARTRIDGE CAUSED MY PUMP TO OVER-DELIVER. IT WAS DANGEROUS, AND HAD I LIVED ALONE OR NOT HAD CAPABLE HELP, IT COULD HAVE BEEN DEADLY. I DISCUSSED THE SITUATION WITH MY DOCTOR, SENT HER THE DETAILED REPORT ABOVE. SHE REVIEWED MY PUMP SETTINGS WHICH ARE CONSTANTLY UPLOADED ONLINE AND DETERMINED THEY HAD BEEN CORRECT WHEN THIS PROBLEM OCCURRED. SHE COULD SEE NO OTHER ISSUES WITH MY ACTIONS TO EXPLAIN THE PROBLEM. THE ONLY EXPLANATION WAS INSERTION OF A NEW CARTRIDGE WHICH PRODUCED LOW BLOOD SUGAR.