Dosch, Michael P. CRNA PhD
From the Department of Nurse Anesthesia, College of Health Professions, University of Detroit Mercy, Detroit, Michigan.
Accepted for publication January 9, 2014
Published ahead of print May 5, 2014
Conflicts of Interest: See Disclosures at the end of the article.
Reprints will not be available from the author.
Address correspondence to Michael P. Dosch, CRNA, PhD, University of Detroit Mercy, 4001 W. McNichols Rd., Detroit, MI 48221-3038. Address e-mail to firstname.lastname@example.org.
It is critical that the anesthesia provider can answer several questions in the affirmative at the conclusion of a properly performed preanesthesia equipment checkout. Is there oxygen in the oxygen line? Can the patient breathe unobstructed through the circuit? Can they be given a positive pressure breath and can pressure be released from the circuit? Are there leaks in the breathing circuit once reassembled? Some of these functions may be checked automatically during the electronic self-check routine, or they may need to be performed by the user.1,2
Anesthesia breathing circuits may be obstructed by plastic wrap fragments, gas analysis port caps, mold flash, clogged filters, or other debris. Recent reports show that the consequences of partial or complete breathing circuit obstruction include difficult or impossible ventilation (either manual or mechanical), excessive end-expiratory or sustained pressure, bilateral pneumothorax, and death.3–13 The purpose of this report was to examine how current anesthesia workstations with automated checkout detect and respond to complete obstruction of the inspiratory or expiratory limb of the circle breathing circuit.
No patients were connected to the workstations used, so neither informed consent nor IRB approval was obtained. Faults were introduced in the breathing circuit only momentarily. These faults were removed, and the workstations checked to ensure they were safe for patient care at the end of testing.
ADU workstations (GE Healthcare Inc., Madison, WI) had been in use in all anesthetizing locations at 1 site for >10 years. During installation and training on newly purchased Aisys workstations (GE Healthcare Inc., Madison, WI) in October 2012, it was noted that the electronic checkout final screen was different; it did not remind users to check the breathing circuit for unobstructed flow or for competence of the inspiratory and expiratory unidirectional valves (Figs. 1 and 2).
To determine how the Aisys and 2 other currently available workstations detect and respond to breathing circuit obstruction, a fault was created. Layers of plastic material (from the wrap enclosing the facemask) were used to completely occlude the junction between the corrugated expiratory limb of the plastic portion of the breathing circuit, and its mount on the machine (Fig. 3). The automated checkout was performed, noting the ability of the workstation to detect the occlusion, and how it responded. The response of these machines to an inspiratory limb occlusion, created in similar fashion, was also tested. This simulation was performed on the Aisys, ADU, and Apollo (Drager Medical Inc., Telford, PA).
Although it was assumed that all examples of a particular workstation model would respond identically to a breathing circuit obstruction, repeated trials were performed to ensure that the responses observed were not due to the particular workstation used. Five examples of each model were tested with inspiratory and expiratory obstructions. Statistical analyses were not performed.
In the presence of an expiratory limb obstruction, the Aisys displayed an error message in the course of its electronic checkout, indicating that it could not measure circuit compliance and suggested “check flow sensors.” However, it allowed the user to accept this condition and initiate patient care (Fig. 4, Table 1). A simulated case was started using a spare breathing bag attached at the elbow as a test lung, with fresh gas flow 6 L/min, tidal volume 600 mL, and respiratory rate 10 breaths/min in volume control mode (Fig. 5). With a complete expiratory limb occlusion, the mechanical ventilator can inflate the simulated lung, but gas cannot escape from it. Within a very brief interval (<2 minutes), peak, mean, and end-expiratory pressure increased to approximately 40 cm H2O, high-priority alarms sounded, indicating high peak pressure, and the message “PEEP high. Blockage?” appeared (Fig. 5). Note that these alarms did not appear during performance of the automated checkout, but only after simulated patient care had been initiated. Similar results were obtained when initiating a simulated case using the manual limb of the breathing circuit. Inflation of the simulated lung was possible by squeezing the breathing bag, but gas could not escape from the test lung, and the same alarms followed promptly.
With an inspiratory limb occlusion, the Aisys failed its electronic checkout earlier, because the bellows could not empty through the inspiratory limb. On repeating the test, the ventilator check failed again, and the Aisys displayed a visual reminder to “ventilate manually!” However, the Aisys again allowed the user to start a case (Table 1).
The responses of the ADU and Apollo were quite different (Table 1). With the expiratory limb occluded, the ADU error message used the word “failed” twice. With an inspiratory limb occlusion, the error message in the ADU referred to “probable disconnection.” In one of 5 trials of the ADU with an inspiratory limb obstruction, the wording of the error message varied slightly, referring to leakage. In the Apollo, one of 2 error messages occurred whether the inspiratory or expiratory limb was occluded (see Table 1). One of these (“System error. Device cannot be used”) was unrecoverable, requiring the user to turn the workstation off, and then on, before it would clear. The other error message identified the source of the problem as a leak in the ventilator or breathing circuit and allowed the user to repeat the test. The occurrence of one or the other error was not related to which valve was occluded, which valve was occluded first, or which error message had previously appeared. In 3 cases, the same error appeared for both occlusions; in the other 2 cases, inspiratory and expiratory occlusions caused the appearance of one of each of the 2 error messages. Neither the ADU nor the Apollo allowed the user to proceed to the next step in the automated checkout in the presence of occlusion in either limb. Neither the ADU nor the Apollo allowed the user to start a case.
Most current workstations have a checkout that is partly automated, and partly check reminders for actions that must be performed manually by the user. It can be difficult to determine exactly what is checked during the automated portion of the checkout.16,17 If tests for breathing circuit occlusion are not performed before each case, a patient may be induced using a circuit that cannot ventilate a patient or in which a high, sustained pressure builds very quickly. Add this emergent mechanical difficulty to the normal physiologic instability and high task burden associated with the first moments after induction, and a crisis occurs that demands a quick and accurate response.18–20 The differential diagnosis includes complete bronchospasm, esophageal intubation, and a kinked endotracheal tube.
In a recent report from the Closed Claims database (covering closed claims from 1990 to 2011), problems with breathing circuits represented 20% of claims related to gas delivery equipment.21 In half of the breathing circuit claims, ventilation by self-inflating manual ventilation device (Ambu) was not available, or intitiated too late, and the outcome was death or brain damage. In half of these 8 claims, difficult ventilation was misdiagnosed as bronchospasm. Most of the breathing circuit claims (6 of 8) were judged preventable with a proper preanesthesia checkout.21
The current Pre-Anesthesia Checkout (2008 PAC) requires users to check that gas flows properly through the breathing circuit during both inspiration and exhalation. This check must be performed not only at the start of the day but also before each case.1 The 2008 PAC suggests using a test lung attached at the elbow, during both manual and mechanical ventilation. Two other means for detecting occlusions or malfunctioning valves have been suggested. The user can check for obstruction in the circle breathing system by breathing through it.22 However, this presents a danger of disease transmission and increases occupational exposure to gases and vapors. Providers can also check for expected breathing bag movement at the start of denitrogenation, immediately after placing the mask over the patient’s face.23 This approach leaves little time to correct errors, but at least, an obstruction may be caught before induction (and the cessation of spontaneous respiration).
In conclusion, although manufacturers’ automated electronic checkout procedures in 3 current anesthesia workstations all detected an occluded inspiratory or expiratory limb of the breathing circuit, they varied in how clearly they alerted the user and whether they allowed a case to be initiated. The Aisys, unlike ADU and Apollo, allowed the user to accept the condition and initiate care. Users should be aware of the differences between checkout routines and develop local guidelines to ensure that anesthesia providers can properly interpret the results of the self-tests and can perform a test for breathing circuit occlusion independent of the automated checkout.
Name: Michael P. Dosch, CRNA PhD.
Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.
Attestation: Michael P. Dosch approved the final manuscript.
Conflicts of Interest: I have no ongoing financial relationship with the manufacturers of any devices mentioned here. I have presented at state and national meetings with sponsorship by GE in the past. I served as an invited consultant to Dräger Medical on 1 occasion.
This manuscript was handled by: Maxime Cannesson, MD, PhD.
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