PIRS-2 News & Safety Resources

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.