Equipment Events




Carbon Monoxide in the Anesthesia Circuit


Definition


Carbon monoxide present in the anesthesia breathing circuit


Etiology


Carbon monoxide is produced by degradation of volatile anesthetic agents in the presence of desiccated CO 2 absorbents




  • The amount of carbon monoxide produced depends upon the degree of desiccation, temperature in the breathing circuit, volatile anesthetic concentration, and fresh gas flow




    • Production is greatest with absorbents containing strong bases (e.g., KOH > NaOH)



    • Production is greatest with desflurane and isoflurane but has also been reported with sevoflurane




  • CO 2 absorbent desiccation is typically caused by fresh gas flow into circle system of anesthesia workstation allowing CO 2 absorbent drying (e.g., fresh gas flow left on overnight)



Typical Situations


After period of anesthesia workstation nonuse (e.g., over a weekend)


Prevention





  • Use CO 2 absorbents whose composition does not facilitate significant volatile anesthetic degradation



  • Awareness of the potential for carbon monoxide production if a machine has not been used for some time



  • Develop institutional, hospital, and/or departmental policies regarding steps to prevent desiccation of the CO 2 absorbent, such as




    • Turn off all gas flow when the workstation is not in use



    • Change the absorbent regularly



    • Change absorbent whenever the color change indicates exhaustion



    • Change all absorbent (both cartridges in a two cartridge system)



    • Change absorbent when uncertain of the state of hydration



    • If compact canisters are used, consider changing them more frequently



    • Place a date on the canister when it is changed



    • If available, monitor patient using a multiwavelength pulse oximeter capable of continuously measuring carboxyhemoglobin




Manifestations





  • Moderate decrease in O 2 saturation



  • Unexpectedly rapid change of absorbent indicator color after anesthesia induction



  • Unusually high temperature of absorbent canister



  • On emergence from anesthesia, unexplained confusion, nausea, dyspnea, headaches, blurred vision, and dizziness



Similar Events





Management





  • Use high fresh gas flow to purge carbon monoxide from breathing circuit



  • Confirm diagnosis




    • Draw an arterial blood sample for co-oximetry analysis, looking for elevated carboxyhemoglobin (COHb)




  • Ventilate lungs with 100% O 2 to decrease the half-life of COHb




    • Patient may require mechanical ventilation until COHb has fallen to safe levels




  • Replace absorbent with fresh absorbent



Complications





  • Hypoxemia



  • Nausea, vomiting, severe headache, syncope



  • Coma, convulsions



  • Myocardial ischemia



  • Neuropsychologic abnormalities



  • Cardiac arrest



Suggested Reading


  • 1. Olympio M.A.: Carbon dioxide absorbent desiccation safety conference convened by APSF. APSF Newsletter 2005; 20: pp. 25-29.
  • 2. Berry P.D., Sessler D.I., Larson M.D.: Severe carbon monoxide poisoning during desflurane anesthesia. Anesthesiology 1999; 90: pp. 613-616.
  • 3. Woehlck H.J., Dunning M., Connolly L.A.: Reduction in the incidence of carbon monoxide exposures in humans undergoing general anesthesia. Anesthesiology 1997; 87: pp. 228-234.
  • 4. Feiner J.R., Rollins M.D., Sall J.W., et. al.: Accuracy of carboxyhemoglobin detection by pulse co-oximetry during hypoxemia. Anesth Analg 2013; 117: pp. 847-858.



  • Circle System Expiratory Valve Stuck Closed


    Definition


    The expiratory valve of a circle system is “stuck closed” when the valve does not open properly during expiration, thus preventing exhalation of gas from the lungs


    Etiology





    • Valve components are misassembled



    • Extra parts or foreign bodies are present in the valve assembly



    • Dirt, blood, moisture, or secretions contaminating the valve assembly



    Typical Situations


    After cleaning or reassembly of the valve


    Prevention





    • Ensure that only trained individuals assemble and maintain the valve systems



    • Conduct a thorough preuse check of the circle system and the unidirectional valves




      • Check for normal appearance of the valve assembly



      • Check that the valve disk moves appropriately when breathing from the circuit or when ventilating a “test lung” (reservoir bag)




        • Check breathing circuit pressure at end-expiration during mechanical ventilation of the test lung




          • With a standing bellows ventilator, the pressure should be 2 to 3 cm H 2 O



          • With a piston or hanging bellows ventilator, the pressure should be zero



          • An automated machine check would probably not detect this problem






    Manifestations





    • Progressive increase in PIP and PEEP




      • The increase in PIP may plateau at a high value owing to the performance envelope of the ventilator and to gas escaping through a high-pressure relief valve during inspiration



      • The continuing pressure alarm will sound after 15 seconds if pressure limit is set appropriately




    • Hypotension secondary to increased intrathoracic pressure and impaired venous return




      • Delayed or diminished response to injected vasoactive medications and fluids




        • They may not reach the arterial circulation because of impeded venous return





    • Increasing difficulty in ventilating the patient’s lungs due to apparent low total thoracic compliance (i.e., “stiff lungs”)



    • Decreased or absent ET CO 2



    • Decreased O 2 saturation



    • Pulmonary barotrauma




      • Pneumothorax



      • Pneumomediastinum



      • SC emphysema




    Similar Events





    Management





    • Disconnect the patient from the anesthesia breathing circuit to relieve high intrathoracic pressure



    • Use an alternative system to ventilate the lungs (e.g., self-inflating bag or a nonrebreathing system)





    • If the circle system must be used




      • Reduce the fresh gas flow into the circuit



      • Ventilate the lungs manually, disconnecting the patient from the breathing circuit as often as necessary to relieve the excess pressure



      • Attempt to relieve the obstruction




        • Tap the valve dome



        • Remove the expiratory valve disk




          • Increase the fresh gas flow to minimize rebreathing of CO 2




        • Ventilate the lungs




      • Repair or replace the expiratory valve or valve-CO 2 absorber assembly




    Complications





    • Hypotension



    • Pneumothorax



    • Following relief of the high intrathoracic pressure




      • Hypertension and tachycardia due to relief of the venous obstruction and accumulated doses of vasoactive drugs reaching the arterial circulation




    Suggested Reading


  • 1. Eisenkraft J.B.: Hazards of the anesthesia delivery system. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 591-620.
  • 2. American Society of Anesthesiologists : ASA recommendations for pre-anesthesia checkout procedures. 2008. American Society of Anesthesiologists Park Ridge, Ill Available at www.asahq.org/For-Members/Clinical-Information/2008-ASA-Recommendations-for-PreAnesthesia-Checkout.aspx



  • Circle System Inspiratory Valve Stuck Closed


    Definition


    The inspiratory valve of a circle system is “stuck closed” when it does not open properly during inspiration, thus preventing ventilation of the lungs.


    Etiology





    • Valve components are misassembled



    • Extra parts or foreign bodies are present in the valve assembly



    • Dirt, blood, moisture, or secretions contaminating the valve assembly



    Typical Situations


    After cleaning or reassembly of the valve


    Prevention





    • Ensure that only trained individuals assemble and maintain the valve systems



    • Conduct a thorough preuse check of the circle system and the unidirectional valves




      • Automated check of the newer anesthesia workstations should detect this fault



      • Check for normal appearance of the valve assembly



      • Check that the valve disk moves appropriately when breathing from the circuit or when ventilating a “test lung” (reservoir bag)



      • Check that PIP is normal during ventilation of the test lung and that there is appropriate flow of gas into the test lung during inspiration




    Manifestations





    • Markedly increased PIP




      • The high-pressure alarm may sound




        • Most anesthesia workstations have a default setting of 40 cm H 2 O





    • Apparent low total thoracic/pulmonary compliance




      • The reservoir bag feels “stiff” during manual ventilation




    • Diminished or absent breath sounds



    • Decreased expired minute volume



    • Absent or decreased ET CO 2




      • Increased arterial PaCO 2




    • Hypoxemia



    Similar Events





    Management





    • Use an alternative system to ventilate the lungs (e.g., self-inflating bag or a nonrebreathing system)




      • Maintain oxygenation and ventilation



      • Convert to an IV anesthetic if necessary




    • To diagnose the obstruction in the inspiratory limb of the circle system




      • Disconnect the patient from the anesthesia breathing circuit at the Y piece and activate the O 2 flush




        • If the breathing circuit pressure rises dramatically but there is no gas flow from the circuit, the inspiratory limb is obstructed




      • Inspect the valve assembly




    • If the circle system must be used




      • Remove the disk from the inspiratory valve, effectively leaving the valve stuck open



      • Maximize the fresh gas flow to minimize rebreathing



      • Ventilate the patient’s lungs




    Complications





    • Hypoventilation



    • Hypoxemia



    • Hypercarbia



    Suggested Reading


  • 1. Eisenkraft J.B.: Hazards of the anesthesia delivery system. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 591-620.
  • 2. Walker S.G., Smith T.C., Sheplock G., Acquaviva M.A., Horn N.: Breathing circuits. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 95-124.



  • Circle System Valve Stuck Open


    Definition


    A valve in the circle system is “stuck open” when it does not fully occlude the inspiratory or expiratory limb, thereby permitting rebreathing of exhaled gases containing CO 2 .


    Etiology





    • The valve disk or valve ring is broken or deformed



    • Valve components are misassembled or missing



    • Extra parts or foreign bodies are present in the valve assembly



    • Dirt, blood, moisture, or secretions contaminating the valve assembly



    Typical Situations





    • After cleaning or reassembly of the valve



    • Long-duration cases with humidification



    Prevention





    • Ensure that only trained individuals assemble and maintain the valve systems



    • Conduct an appropriate preuse check of the circle system and the one-way valves




      • Check for normal appearance of the valve assembly



      • Check that the valve disks move appropriately when breathing from the circuit or when ventilating a “test lung” (reservoir bag)



      • Check for agreement between the tidal volume set on the ventilator and the volumes delivered and exhaled from the test lung



      • An automated machine check would most likely not detect this problem




    Manifestations





    • Increased inspiratory CO 2




      • This is pathognomonic for rebreathing or for exogenous administration of CO 2



      • Observe both the digital readout of FiCO 2 and the capnogram




        • FiCO 2 > 0 to 1 mm Hg



        • Elevated baseline of capnogram





    • Increased ET CO 2 and PaCO 2




      • Hypertension, tachycardia, and vasodilation secondary to hypercarbia




    • Hyperventilation in patients who are breathing spontaneously



    • Reverse flow alarm may be activated by a spirometer that can sense the direction of flow and is located in the limb of the incompetent valve



    • If the incompetent valve is in the inspiratory limb, there may be a disparity between the inspiratory movement of the ventilator bellows and the expired volumes measured by a spirometer in the expiratory limb



    Similar Situations





    • Failure or exhaustion of the CO 2 absorbent



    • CO 2 absorber bypass valve accidentally left in the bypass position



    • CO 2 absorber out of circuit



    • CO 2 infused into the circuit from a pipeline supply or tank



    Management





    • Check for CO 2 absorbent exhaustion and replace if necessary



    • Check that CO 2 absorber bypass valve (if present) is correctly positioned



    • Check that the CO 2 absorber (disposable cartridge) is in the circuit



    • Use an alternative system to ventilate the lungs (e.g., self-inflating bag or a nonrebreathing system) if the ET CO 2 or PaCO 2 is significantly increased or if there are systemic signs of hypercarbia




      • Repair or replace the valve assembly or anesthesia workstation as soon as feasible




    • Maintain anesthesia with IV agents



    • If the circle system must be used




      • Maximize fresh gas flow into the breathing circuit



      • Ventilate the patient’s lungs




    Complications





    • Hypercarbia




      • Tachycardia



      • Hypertension




    • Arrhythmias



    Suggested Reading


  • 1. Walker S.G., Smith T.C., Sheplock G., Acquaviva M.A., Horn N.: Breathing circuits. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 95-124.
  • 2. Eisenkraft J.B., Jaffe M.B.: Respiratory gas monitoring. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 191-222.
  • 3. Giordano C.R., Gravenstein N.: Capnography. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 245-255.



  • Common Gas Outlet Failure


    Definition


    Common (fresh) gas outlet failure is the disconnection or obstruction of the fresh gas supply between the common gas outlet of the anesthesia workstation and the anesthesia breathing circuit (many contemporary anesthesia workstations do not have a user-accessible common gas outlet).


    Etiology





    • Disconnection of the connecting hose from the common gas outlet or the CO 2 absorber housing



    • Obstruction of the common gas outlet or connecting hose



    • Failure of the auxiliary common gas outlet present on some anesthesia workstations (e.g., GE/Datex-Ohmeda Aestiva and the GE Aisys Carestation)



    Typical Situations





    • After the connecting hose has been disconnected from the common gas outlet so that the common gas outlet can be used as a source of O 2 or an O 2 -air mixture for delivery to a face mask or nasal cannulae



    • After cleaning or maintenance of the anesthesia workstation



    Prevention





    • Use an antidisconnect device at each end of the connecting hose between the common gas outlet and the anesthesia breathing circuit



    • Do not connect O 2 nasal cannulae or face masks to the common gas outlet or connecting hose




      • Connect to a separate O 2 source



      • Connect to auxiliary O 2 flowmeter



      • Connect to the Y piece of the breathing circuit



      • Connect to auxiliary common gas outlet if an air/O 2 mixture is desired to avoid an O 2 enriched atmosphere




    • Conduct a thorough preuse check of the anesthesia workstation



    • Discourage nonessential activity in the vicinity of the anesthesia workstation and the anesthesia breathing circuit



    Manifestations





    • The reservoir bag or ventilator bellows will progressively empty




      • In ventilators in which the bellows falls during exhalation (“hanging bellows”), the loss of gas from the circuit may not be apparent




    • When the O 2 flush is activated, there will be a loud sound of rushing gas but the reservoir bag or ventilator bellows will not fill



    • The breathing circuit low airway pressure alarm will sound



    • The low minute ventilation alarm may sound



    • Decrease in the O 2 concentration of the inspired gas



    • The signs of hypoventilation, hypoxemia, and hypercarbia will appear later



    Similar Events


    Major leak in the anesthesia circuit from other causes (see Event 69, Major Leak in the Anesthesia Breathing Circuit )


    Management





    • Increase the fresh gas flow into the anesthesia breathing circuit




      • This will not compensate for the leak from a disconnection of the common gas outlet or connecting hose




    • Switch to the reservoir bag, close the pop-off valve, and attempt to fill the anesthesia breathing circuit by activating the O 2 flush




      • Activating the O 2 flush will not fill the anesthesia circuit




        • If the common gas outlet is obstructed, there will be no flow of gas



        • If the connecting hoses are disconnected, there will be a loud sound of escaping gas but the reservoir bag will not fill





    • Scan for an obvious disconnection or interruption of the hose between the common gas outlet and the anesthesia breathing circuit




      • Reconnect the hose




    • Check whether the auxiliary common gas outlet (present on some anesthesia workstations) has been selected



    • If problem persists, use an alternative system to ventilate the lungs (e.g., self-inflating bag or a nonrebreathing system)




      • Call for help to identify and correct the problem



      • If necessary, replace the anesthesia workstation if this is feasible




    • Maintain anesthesia with IV agents until the common gas outlet is restored



    • Inform biomedical engineering of the failure and have the equipment inspected



    Complications





    • Hypoventilation




      • Hypercarbia



      • Hypoxemia




    • Awareness



    Suggested Reading


  • 1. Raphael D.T., Weller R.S., Doran D.J.: A response algorithm for the low pressure alarm condition. Anesth Analg 1988; 67: pp. 876.
  • 2. Eisenkraft J.B.: The anesthesia machine and workstation. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 25-63.



  • Drug Administration Error


    Definition


    A drug administration error involving a syringe, ampule, or infusion pump may occur in the following ways:







      • Ampule swap: The incorrect drug is drawn up into a labeled syringe or infusion pump



      • Syringe swap: Medication from the wrong syringe is administered to the patient



      • Infusion pump error: Incorrect drug or drug dosage administration from an infusion pump




    Etiology





    • Failure to label syringes or infusion pump



    • Incorrect labeling of syringes or infusions



    • Failure to read the label on the ampule, syringe, or infusion pump




      • Mix-up of drugs with similar names (e.g., epinephrine and ephedrine)



      • Mix-up of drugs with similar packaging (drugs from different vendors may look similar)



      • Wrong drug in storage bin




    • Failure to properly dilute a concentrated preparation of a drug (e.g., regular insulin)



    Typical Situations





    • When the anesthesia professional is working in unfamiliar settings or with unfamiliar devices



    • When drug packaging or ampules are changed (e.g., new vendor)



    • When drugs are restocked



    • When there is time pressure or in the presence of distractions



    • When ampules have a similar appearance, especially if they are located close to each other in a drug cart



    • When syringe and infusion pump labels are written by hand



    • When syringes are prepared by other personnel



    • When it is dark in the OR or procedure room



    Prevention





    • Check the drug name and concentration on each drug ampule carefully (ASTM standard D 6398-08)



    • Use drug ampules whose labels conform to ASTM standard D 5022-07



    • Label syringes carefully




      • Use preprinted, color-coded adhesive syringe labels (ASTM D 4774-11e1)



      • For emergency drugs, use “ready to use” syringes (ASTM D 4775-88/D 4775M-09)



      • Discard unlabeled syringes



      • Discard syringes if there is any doubt about their actual contents




    • Use commercially premade syringes (especially with high-potency medications requiring dilution)



    • Arrange drug trays to separate similar appearing or named medications



    • Pharmacy should notify anesthesia professionals when changing drug vendors



    • Use “high risk” labels for high-risk drugs (e.g., neuromuscular blockers)



    Manifestations





    • Unusual response or lack of response to drug administration




      • Unusual increase or decrease in BP or HR



      • The awake patient may complain of an unusual sensation




        • Pounding heart or palpitations



        • Lightheadedness



        • Unexpected change in level of consciousness



        • Visual disturbance



        • Unexpected muscle weakness




      • The anesthetized patient may exhibit




        • Hypertension, tachycardia, hypotension, bradycardia



        • Unexpected occurrence or persistence of muscle relaxation



        • Unexpected change, or lack of change, in level of consciousness





    • Incorrect ampule or vial found to be open in the anesthesia professional’s work area



    Similar Events





    Management





    • If the error in drug administration is recognized immediately after injection




      • Stop the IV line carrying the drug



      • Disconnect IV tubing from IV catheter and drain IV line



      • If there is a BP cuff on the same arm as the IV catheter, inflate it to slow down the entry of the drug into the central circulation




    • Maintain the patient’s airway and ensure adequate oxygenation and ventilation




      • If the medication error involved administration of a muscle relaxant to an awake patient




        • Reassure the patient, provide sedation with a short-acting IV agent, and assess the need to place an ETT for ventilation and anesthesia



        • Assess neuromuscular function with a nerve stimulator and reverse neuromuscular blockade when sufficient recovery has occurred




      • If the medication error involved administration of a muscle relaxant to an anesthetized patient




        • Assess neuromuscular function with a nerve stimulator and reverse neuromuscular blockade when sufficient recovery has occurred



        • Maintain anesthesia until adequately reversed





    • If the patient is hypotensive (see Event 9, Hypotension )




      • Expand the circulating fluid volume rapidly



      • Administer a vasopressor (e.g., phenylephrine IV, 50 to 100 μg bolus)



      • Treat any associated bradycardia with atropine IV, 0.6 mg bolus; or glycopyrrolate IV, 0.2 to 0.4 mg bolus, repeated as necessary




    • If the patient is hypertensive (see Event 8, Hypertension )




      • Depending on the drug and dose, the hypertensive episode may resolve quickly. In particular, it is often better to wait for the effects of epinephrine (especially tachycardia) to resolve spontaneously than to treat it aggressively with β-blockade, which can lead to unopposed adrenergic effects



      • Administer a short-acting vasodilator (NTG IV 0.2 to 1 μg/kg/min; sodium nitroprusside IV 0.2 to 2 μg/kg/min)



      • Consider treating prolonged tachycardia




        • Esmolol IV, 0.5 mg/kg loading dose, followed by an infusion as necessary to control the HR



        • Labetolol IV, 5 to 20 mg, repeat as needed





    • Attempt to determine what drug was administered




      • Check infusion pumps




        • Check to see whether infusions are running



        • Check drug infusion settings and labeling



        • Check tubing from source to patient




      • Check the syringes and ampules used during the case




        • Check the label on the syringe just used to determine whether it was the desired one



        • Check to see whether one syringe has an unexpectedly low volume of drug remaining




      • Inspect opened ampules and vials to determine whether an incorrect medication was opened



      • Have the trash and “sharps” containers impounded to allow inspection of ampules, vials, and syringes at a later time




    • Treat any additional side effects of the medications that were administered



    Complications





    • Awareness



    • Residual or prolonged neuromuscular blockade



    • Hypoventilation, hypoxemia, or hypercarbia



    • Myocardial ischemia or infarction



    • Cerebral ischemia



    • Arrhythmias



    • Cardiac arrest



    Suggested Reading


  • 1. Eichhorn J.H.: APSF hosts medication safety conference consensus group defines challenges. APSF Newsletter 2010; 25: pp. 1-9.
  • 2. Stratman R.C., Wall M.H.: Implementation of a comprehensive drug safety program in the perioperative setting. Int Anesthesiol Clin 2013; 51: pp. 13-30.
  • 3. Cooper L., Nossaman B.: Medication errors in anesthesia: a review. Int Anesthesiol Clin 2013; 51: pp. 1-12.
  • 4. Orser B.A., Hyland S., U D , Sheppard I., Wilson C.R.: Review article: improving drug safety for patients undergoing anesthesia and surgery. Can J Anaesth 2013; 60: pp. 127-135.



  • Electrical Power Failure


    Definition


    Electrical power failure is loss of all or part of the electrical power supply, including the possible loss of the emergency power generation system.


    Etiology





    • Power failure external to the hospital



    • Power failure internal to all or part of the hospital



    • Failure of an electrical circuit within the OR



    • Failure of the emergency power generation system or battery backup system



    Typical Situations





    • During severe weather



    • During or after a fire in the hospital



    • Following a natural disaster (e.g., earthquake)



    • During or after construction within or outside the hospital



    Prevention





    • Ensure that backup batteries in anesthesia equipment are charged and that the batteries continue to hold charge




      • Nickel-cadmium batteries may need to be fully discharged occasionally to maintain their ability to hold a full charge




    • Plug critical electrical equipment into circuits connected to the emergency power generation system (typically red colored outlets)



    • Test the emergency power generation system on a regular basis, and correct any faults that might prevent a rapid switchover to emergency power



    • Use an uninterruptible power supply (UPS) for critical pieces of equipment




      • Check the operating manual of each anesthesia workstation and ventilator for the need of a UPS




        • Some newer anesthesia workstations have a battery backup that can power the ventilator for a short time





    • Conduct periodic power failure drills with OR staff



    Manifestations





    • Failure of primary and emergency electrical power




      • Room lights go off



      • All electrical equipment without a battery backup goes off



      • Electronically controlled or powered anesthesia workstations without battery backup will stop working




        • Some anesthesia ventilators are both pneumatically powered and pneumatically controlled and will continue to function



        • Most contemporary anesthesia ventilators are electronically controlled or electrically powered and will stop workingDelivery of anesthetic gases to the circuit may also stop





    • Failure of primary power only; emergency power is on




      • Lights and equipment go off transiently




        • There will be a variable time interval while emergency generators are activating and power is restored to the emergency power outlets




      • When switching to emergency power, microprocessor-based equipment may reset to factory defaults or lock up owing to power surge



      • Equipment that is not connected to an emergency power outlet will not operate




    Similar Events





    • Localized failure of a single outlet or circuit



    • Failure of an individual monitor, device, or light



    • Tripping of a ground fault circuit interrupter (GFCI) outlet



    Management





    • Find an emergency flashlight




      • A flashlight should be stored in the anesthesia cart



      • Many ORs have battery-powered emergency lights



      • Use the laryngoscope light to assist in finding other lights



      • Use a smartphone flashlight



      • Open the OR door to let in light from the corridor




    • If emergency power is on, ensure that all critical devices are connected to emergency power outlets



    • Ensure that the O 2 supply is still intact




      • If not, disconnect wall O 2 hose, open backup O 2 cylinders on the anesthesia workstation, and manually ventilate the patient’s lungs




    • If both the primary and emergency power systems have failed




      • The internal backup battery may power the anesthesia workstation for a short time, usually 30 to 60 minutes



      • Prolong battery life in workstations by reducing screen brightness to a minimum



      • Check the anesthesia workstation to determine what systems are functional. If there is any doubt about ability to oxygenate and ventilate the patient using the anesthesia workstation, ventilate with a self-inflating bag and a separate O 2 source




        • Check gas flow




          • If there is no gas flow, activate the manual emergency O 2 flowmeter if available and ventilate with self-inflating bag. Send help to obtain additional O 2 tanks and regulator




        • Check the ventilator to ensure the patient’s lungs are being mechanically ventilated




          • If the ventilator is not operating, initiate manual ventilation using the anesthesia workstation and breathing circuit or self-inflating bag



          • Consider manual ventilation to prolong battery life of the anesthesia workstation




        • Check that monitors are functioning




          • Send for battery-operated transport monitor






    • Confer with the surgeon




      • Consider the status of the surgical procedure and its urgency



      • If the surgery is at a critical point, the highest priority for lighting should go to the surgical field




    • Establish monitoring of the patient




      • Place esophageal or precordial stethoscope



      • Place manual BP cuff and check periodically



      • Palpate peripheral pulses or have the surgeon palpate arterial pulses in the operative field



      • Check that routine monitors with battery backups are still operating




        • Allocate available battery-operated transport monitors (high-acuity cases have priority)





    • Consider the need for additional IV anesthesia drugs



    • Ensure that OR staff and engineers are informed of the power failure and have activated the hospital disaster plan if appropriate



    • Allocate personnel and equipment where needed most




      • Patients undergoing CPB




        • Some pump oxygenators have battery backups but all have hand cranks




      • Complex or urgent surgical cases



      • ICU (all ventilators may be inoperative if there has been a large-scale power loss)



      • Reassess allocation of personnel and resources as the situation evolves




    • Determine time until power will be restored, if possible




      • If power supply is likely to take more than a few minutes to restore, terminate all non-emergent cases as soon as possible



      • Do not start non-emergent cases until a reliable electrical power supply is ensured




    Complications





    • Hypoxemia



    • Surgical mishap



    • Hemodynamic instability



    • Intraoperative awareness



    Suggested Reading


  • 1. Ehrenwerth J., Seifert H.A.: Electrical and fire safety. Ehrenwerth J. Eisenkraft J.B. Berry J.M. Anesthesia equipment: principles and applications . 2013. Saunders Philadelphia: pp. 621-652.
  • 2. Ehrenwerth J., Seifert H.A.: Electrical and fire safety. Barash P.B. Cullen B.F. Stoelting R.K. et. al. Clinical anesthesia . 2013. Lippincott Williams and Wilkins Philadelphia: chapter 8
  • 3. NFPA-99 : Health care facilities code. 2012 ed. 2012. National Fire Protection Association Quincy, Mass
  • 4. Eichhorn J.H., Hessel E.A.: Electrical power failure in the operating room: a neglected topic in patient safety. Anesth Analg 2010; 110: pp. 1519-1521.
  • 5. Carpenter T., Robinson S.T.: Response to a partial power failure in the operating room. Anesth Analg 2010; 110: pp. 1644-1646.
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    Feb 22, 2019 | Posted by in ANESTHESIA | Comments Off on Equipment Events
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