Description of Event or Problem · 0
DURING A LIVER TRANSPLANT SURGERY, THE CZIMMER BIOMET INTELLICART SYSTEM SUCTION MACHINES KEPT FAILING. THIS PATIENT WAS CRITICALLY ILL AND AN ACTIVE MASSIVE TRANSFUSION PROTOCOL FOR NEARLY 12 HOURS. DURING THE CASE, THE MACHINES WOULD LOSE SUCTION; HOWEVER, NO ERROR MESSAGE WAS DISPLAYED ON THESE DEVICES THAT WOULD ALERT SURGICAL STAFF/PHYSICIANS THAT THE SUCTION WAS NO LONGER WORKING OR STATING A LOSS OF SUCTION AT ANY TIME. WHEN OBSERVING THE MACHINES TO TROUBLESHOOT, THE MACHINES UNITS/CANISTERS WERE NOT FULL. THE MANIFOLDS WERE SWITCHED OUT MULTIPLE TIMES IN AN EFFORT TO REGAIN SUCTION, AS WELL. THIS WOULD HELP FOR A SHORT TIME, BUT THE CZIMMER SUCTION MACHINE WOULD ULTIMATELY STOP SUCTIONING. THE STAFF WENT THROUGH 8 DIFFERENT DEVICES OVER THE COURSE OF THIS PATIENT'S OPERATIVE COURSE. IT IS ALSO IMPORTANT TO NOTE, THAT THE PHYSICIANS WERE VERBALLY EXPRESSING THE PATIENT WAS NOT CLOTTING, SO IT'S DIFFICULT TO DETERMINE IF CLOTTING BLOOD WAS THE CAUSE OF SUCTION FAILURE. PATIENT WAS STATUS POST LIVER TRANSPLANT IN 2012. MULTIPLE LIVER/BILIARY ISSUES REQUIRING BILIARY DRAINS, ERCPS (ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY), ETC. PT CODES: 4440, 1888. DEVICE CODE: 2170. REFERENCE REPORTS: MW5184955, MW5184956, MW5184957, MW5184958, MW5184959, MW5184961, MW5184962.