Dear Q&A,
We write to describe an instance of anesthesia machine ventilator failure during provision of anesthesia. The case in point was an emergency vascular operation for a pulseless lower extremity. In preparation for the case, the anesthesia machine checkout was performed on the Dräger GS Premium. All tests confirmed that the anesthesia machine was indeed operational and ready for use.
The patient was brought to the operating room, and, after immediate re-evaluation, the patient was induced. After confirmation of bilateral breath sounds and verification of end-tidal CO2, manual ventilation was discontinued and the mechanical ventilation was initiated. At this point the ventilator immediately alarmed “Ventilator Failure!!!,” “Check APL Valve!!!,” “Apnea Pressure!!” Interestingly, there was no loss of tidal volumes at this point, and, contrary to the alarms, the ventilator appeared to function appropriately. Despite stopping mechanical ventilation and commencing manual ventilation, the alarm continued. After several minutes of inspection of the circuit, a small cut in the APL valve tubing was discovered. The tubing was replaced, the alarms ceased, an uneventful anesthetic ensued, and there were no untoward effects on the patient.
In an effort to delineate whether this type of ventilator failure can be discovered by routine automated machine checkout, we initiated mechanical ventilation mode both before and after making a small cut on the APL valve tubing. The machine passed the ventilator leak test, the system leak test, the compliance test, and the safety relief valves test after making the cut on the APL valve (Page 33, Figures 3, 4); yet , the ventilator flashed the same failure alarms as previously mentioned after mechanical ventilation was initiated.
The purpose of this letter is to remind anesthesia providers that successful automated machine checks, while useful, do not preclude the possibility of machine failures. Indeed, in a previous letter response to the APSF, it was noted by Dräger “No anesthesia system on the market has completely automated all aspects of the checkout procedures and eliminated the need for manual checkout” (APSF Newsletter, winter 2009–2010). The case highlighted above underscores this message and anesthesia team members should keep in mind this unique case of anesthesia machine failure.
Matthew Charous, MD
Michael Presta, DO
Scott Byram, MD
Loyola University Medical Center
Maywood, IL
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