Anesthetic vaporizer mount malfunction resulting in oxygenation failure after initiating cardiopulmonary bypass: Specific recommendations for the pre-bypass checklist

Nischal K. Gautam, Michael L. Schmitz, Luis M. Zabala, Michael W. White, Wesley A. Mckamie, Alyssa Lutz, Charles E. Johnson

Research output: Contribution to journalArticle

Abstract

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 potential 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.

Original languageEnglish (US)
Pages (from-to)183-186
Number of pages4
JournalJournal of Extra-Corporeal Technology
Volume41
Issue number3
StatePublished - Sep 1 2009

Keywords

  • Anesthesia
  • Bypass
  • Cardiopulmonary
  • Complications
  • Equipment
  • Inhalation
  • Intraoperative
  • Safety
  • Standards

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Health Professions (miscellaneous)
  • Cardiology and Cardiovascular Medicine

Fingerprint Dive into the research topics of 'Anesthetic vaporizer mount malfunction resulting in oxygenation failure after initiating cardiopulmonary bypass: Specific recommendations for the pre-bypass checklist'. Together they form a unique fingerprint.

  • Cite this