16th December 2024
Pleasingly there has been an 80% increase in reports to PIRS 2 for 2024 over 2023 following a decreasing trend in numbers prior to that. At the recent ASCVP Annual Scientific Meeting following a presentation on PIRS2 there was discussion on barriers to reporting. One comment was that editorial commentary could be one such barrier.
The purpose of the editorial commentary – reserved for some reports – is to provide helpful information and promote discussion. The PIRS2 Report submission form Q22 asks for “ Permission to publish edited description in ANZCP Gazette &/or website”. We will add – “and to circulate to the PIRS2 email group”
It is very appropriate to submit a report and answer NO to permission to publish. In a case the deidentified data will simply go into the data base and the relevant categories and human factors used in analyses. Descriptive details will remain embargoed. This may give comfort to those hesitant to report.
27th June 2024
The Australian and New Zealand College of Perfusionists (ANZCP) would like to draw your attention to an increase in reporting of issues relating to administration of Protamine and clot formation in the Cardiopulmonary Bypass Circuitry. These reports have been submitted through our Perfusion Incident Reporting System (PIRS) here.
In the last 6 weeks there have been two reports of clotted circuits (a third report pending) where Cardiotomy suction has been continued after protamine administration. One occasion was following an emergent dissection that required urgent recommencement of Cardiopulmonary Bypass – requiring replacement of the HLM circuit.
This practice of pump suction continuing after starting protamine contravenes both ANZCP and AmSECT (American Society of Extracorporeal Technology Guidelines (the latter endorsed by the STS and theAATS )) which require cessation of pump suction prior to any protamine administration. The ANZCP Standards and Guidelines link can be found here (see ANZCP Standard 8.6) and for the AMSECT Guidelines link click here (AMSECT Standard 12.1).
PIRS, like all voluntary reporting, receives only a small fraction of the incidents that occur, therefore the practice of continuing pump suction after a varied percentage of protamine administration is likely widespread.
We will provide further information as it comes to hand and will continue to share best practices and promote safety within our community.
PIRS2 : Human Factors of Reporting Information
PIRS News 10
June 2020
PIRS News 9
September 2019
PIRS News 8
April 2019
PIRS News 7
April 2018
PIRS News 6
January 2018
PIRS News 5
June 2017
PIRS News 4
May 2017
PIRS News 2
February 2017
PIRS News 1
January 2017
Original Article
Reproduced with permission from JECT
Incident Reporting in Perfusion: Current Perceptions on
PIRS-2
Timothy W. Willcox, CCP;* Robert A. Baker, PhD, CCP^
*Green Lane Cardiothoracic Unit, Auckland City Hospital, Auckland, New Zealand; and Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand; and ^Cardiac and Thoracic Surgery Unit, Flinders Medical Centre, Adelaide, South Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
Disconnection of Cobe SMARxT® Tubing from the Venous Outlet of the Terumo Capiox® SX25RX Oxygenator During Cardiopulmonary Bypass
Jane Ottens, BSc, Dip Perf, CCP (Aust),* Robert A. Baker, PhD, Dip, Perf, CCP (Aust),†‡ Andrew J. Sanderson, BSc, Dip, Perf, CCP (Aust),* and Richard F. Newland, BSc, Dip, Perf, CCP (Aust)†
Safety Archive
of the Society of Clinical Perfusion Scientists of Great Britain and Ireland
available here.
Please email admin@anzcp.org for PIRS News 3
