Issue |
J Extra Corpor Technol
Volume 41, Number 3, September 2009
|
|
---|---|---|
Page(s) | 183 - 186 | |
DOI | https://doi.org/10.1051/ject/200941183 | |
Published online | 15 September 2009 |
Technique Article
Anesthetic Vaporizer Mount Malfunction Resulting in Oxygenation Failure after Initiating Cardiopulmonary Bypass: Specific Recommendations for the Pre-Bypass Checklist
* Section of Cardiothoracic Anesthesiology, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, Arkansas
† Division of Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, Arkansas
Address correspondence to: Nischal K. Gautam, Section of Cardiothoracic Anesthesiology, Arkansas Children’s Hospital, 800 Marshall Street, Slot 203, Little Rock, AR 72211. E-mail: gautamnischalk@uams.edu
Received:
27
March
2009
Accepted:
2
August
2009
Modern technologic advances in medicine have allowed commonly used machines to perform safely with very low risk and a high degree of success. To detect or prevent poten-tial malfunctions, professionals routinely perform pre-use checks for equipment such as anesthesia machines and cardiopulmonary bypass (CPB) machines. These machine checklists are not only critical for a safe operation but also have large impacts on outcomes. For example, when malfunctions are encountered that could have potential negative ramifications or adverse outcomes, multi-approach strategies should be used to identify rectifiable causes and find solutions that are practical. This information can be used to promulgate safe practice guidelines. This case report identifies a machine-based contributing factor to precipitous hypoxia on initiation of bypass in one of our patients. After a detailed approach to identify preventable root causes, we made simple additions to our pre-bypass checklist and recom mend these changes to other institutions.
Key words: cardio pulmonary bypass standards complications anesthesia inhalation equipment safety intraoperative complications
© 2009 AMSECT
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