Like so many critical infrastructure elements in developed parts of the world, uninterrupted electrical power is taken completely for granted by today's anesthesia professionals. The only time electrical power gets any real attention is through its absence. Unfortunately, in today's intensely technology-dependent anesthesia care environments, it is the unplanned, and, especially, unanticipated sudden absence of electricity that can disrupt care and, importantly, endanger our patients.
In this issue of Anesthesia & Analgesia, Drs. Carpenter and Robinson1 do us a great service by calling our attention to the important safety issue in anesthesia practice of the loss of electrical power in the operating room (OR). In reviewing this case report, we were surprised to find that this topic is virtually ignored in the standard American textbooks on anesthesia practice,2–4 anesthesia equipment,5,6 and complications in anesthesia,7–9 although all these sources have sections devoted to safety regarding the use of electricity, fires in the OR, and problems with pipelines delivering gases to ORs and anesthesia machines. Even the sparse number of published OR power failure case reports cited by Carpenter and Robinson (including 2 involving cardiopulmonary bypass) are at least middle aged. Therefore, it is very valuable now to have this “wake-up call” that not only appeals to the congenital fascination anesthesia professionals have for OR disaster stories but also provides much-needed stimulus for all anesthesia professionals to (1) be constantly aware in their own minds of this possibility and plan their personal response; (2) verify that the necessary contingency backup equipment is in place and functional in their OR suite; and (3) verify that the responsible medical and infrastructure administrators in their practice settings are fully aware of the potential for and dangers from loss of electrical power in the OR and have detailed plans in place both to prevent it and, failing that, deal with it.
Carpenter and Robinson provide a valuable refresher on several realities of hospital function. One is the simple fact that medical care facilities have 2 types of electrical outlets: the ordinary ones and the ones with the red face plates that are the “emergency” electrical power outlets that are not only normally powered by the regular line power going to all the outlets but also connected to the backup emergency power supply. When the regular line power fails for whatever reason, a sensor detects this and triggers both a transfer switch and the activation of an internal emergency generator that should supply power to the red outlets within 10 to 15 seconds after the line power failure. Because the emergency red outlets are supposed to be the “reliable” uninterruptible ones, all mission-critical equipment such as (in the OR) anesthesia machines (including ventilators), patient monitors, infusion pumps, and cardiopulmonary bypass machines should be connected to red outlets. Ironically, in the case described by Carpenter and Robinson, coincidences conspired suddenly, in the middle of a busy work day, to disable only the red outlets. As is the circumstance in most catastrophic accidents (e.g., nuclear power plant/electrical grid failures or any type of transportation crash), the classic situation involving 2 or more deviations from normal coinciding in time to create a unique discordance and a resulting accident was true here. During a construction project, an electrical relay that had just been worked on fell from its mounting socket; interpreted by the emergency system as a line power failure, this activated a transfer switch that was in the process of being redirected to a new emergency generator that was not in service—no power, either line or emergency—to the red outlets. Other than through a cynical application of “Murphy's Law” (“whatever can go wrong will go wrong”), this was an unforeseeable coincidence leading to a very unusual situation of power failure to everything plugged into a red outlet. One anesthesia machine was unaffected because it was incorrectly connected to a regular line outlet. Individual practitioner responses are described as somewhat varied, but no patient was harmed and there were no known cases of awareness. There are multiple and significant implications of and lessons to be learned from this incident for the more likely (though still extremely rare) occurrence of complete line power failure, both with and without correct activation of the emergency backup generator power to the red outlets. This is the subject matter that is not well covered in the standard textbooks. (It would have been interesting after the event described here to conduct a detailed survey of all the involved anesthesia professionals regarding their prior knowledge of and training in handling a power failure.)
In a line power failure event in which the emergency generator electrical power to the red outlets is rapidly activated, an orderly evaluation and prioritization of power use in the OR will prevent any danger to the patient. The mission-critical equipment should already be connected and should return to function automatically (although any doubt or delay should provoke an “off-on” reboot of the equipment). There should be enough light in the room for general function, but the main lights above the OR table may or may not have power. In either case, it may in some circumstances become necessary for the OR team (surgeon, anesthesia provider(s), and OR staff) to decide whether to continue with the procedure or cease operating as quickly as possible. This obviously will depend on patient-specific details and, importantly, on an assessment from institutional infrastructure administrators, possibly in consultation with power company officials, as to how long the line power will be disabled and how well the emergency generator is handling the load. If surgery is to continue, connecting only the absolutely necessary electrical equipment to the red outlets clearly would be wise.
A line power failure event after which the emergency generator electrical power to the red outlets also fails is a potential life-threatening emergency in the OR. This is when anticipation and planning (including verification of correct placement of functioning backup battery-powered lighting and monitors) as well as prior training are critical. As Carpenter and Robinson note, all current-generation anesthesia machines contain backup batteries. Exactly what the battery will power (e.g., an electric vaporizer?) and how long it should last (with and without driving the ventilator) differ among machines, and this is a key training point that all users of a particular type of machine should know. Although laryngoscopes can provide some light, each anesthesia machine should have a real flashlight—that works—in a drawer at all times. Exactly what monitoring capability will be available via machine batteries also is variable depending on specific configurations and connections. As was noted, portable transport monitors can be valuable in the acute phase. In the absence of any electronic monitors, it is valid to note that for decades anesthesia was administered with a finger on the pulse and an ear-piece stethoscope on the precordium or sternal notch. A number of manual sphygmomanometers should be tucked away in a box in the OR workroom, just in case of a rare need such as in a total power failure. Once it is verified that airway, breathing, and cardiac function are secure and an adequate level of anesthesia is assured, attention must be directed to managing the surgical wound and procedure in near-total darkness. All the while, supervisors and administrators must attempt to get an assessment of the potential for hospital emergency generator power from infrastructure personnel. It is likely that there will not be a reliable estimate of the potential duration of total power failure but there is also the possibility that the emergency generator power may get activated and power the red outlets at any time, or that power from another location or source will be fed in via long industrial-grade extension cords, relieving the acute patient danger. In the absence of any emergency power, however, plans for shutting down the surgical operations in an orderly manner and securing the patients while maintaining their life functions must be implemented. Operating suites should have an “emergency procedures” contingency plan manual with copies at the front desk, in the OR supervisor's office, and in an anesthesia work area (all places where there should also be functioning flashlights). This manual should include preformulated protocols for a disaster response to total power failure. If such an emergency persists past the first 30 minutes or so, responsible supervisors should be implementing plans and issuing directives as specified in the manual. As Carpenter and Robinson point out, communications during such intervals are critical. Hospital infrastructure and engineering administrators and workers usually have their own 2-way radios. Extra radio units on the same system should be kept (fully functional) in a central location for immediate distribution to OR and anesthesia supervisors so that they can be included in real-time in all the communications regarding the evolution of a total power failure in the OR. Note that paging systems might not work during a power outage, making alternative communication methods all the more important.
Whether or not the emergency generator power to the red outlets kicks in quickly, computer-based information and order systems will be affected. Although servers might be preserved with their own instant battery power, work station terminals will at least need time to reboot if they do come back on. As Carpenter and Robinson saw, automated drug dispensing machines might not function, which could disrupt care, particularly outside regular workday hours, and even cause danger to patients. The current heavy reliance on computerization in and around the OR suite may be recent enough to have outstripped the emergency contingency manuals. This should be checked now in every OR suite and relevant new plans and protocols developed as indicated. In some circumstances, the contingency plans will involve emergency deployment of backup (continually refreshed) drug supplies as well as paper forms and pens, adequate quantities of which, again, should always be tucked away in a handy storage location just in case. Return of electrical power after an outage may involve an initial surge that can damage computers and other electronic equipment that do not have a surge protector, representing another potential consequence of failing to anticipate and plan for an OR electrical power failure.
Reflexively, anesthesia professionals may think and say, “That's all fine, but it's not my responsibility to worry about the electrical power.” This “silo-based” ignorance is dysfunctional because an outage can increase danger to patients and result in medical-legal liability if a patient is harmed. It is critical that anesthesia professionals are certain that there is someone in their facility who is qualified, responsible, and constantly vigilant about the electrical power. The ability to provide anesthesia care is resource intensive. Just as it is in the nature of most anesthesia professionals in the developed world to sometimes request the specific types or brands of equipment and supplies they prefer, they must also realize that modern practice and their patients' safety depend on the availability of electrical power (and reliable gas supplies, etc.). Assuming that electricity will always “just be there” is inviting disaster when the extremely rare but potentially devastating failure does happen. Anesthesia professionals should be familiar with the basic utility infrastructure of their OR settings and should consider and plan their response to a utility failure (Table 1). Often, 1 or 2 members of a group or department will take a deeper interest and have extended knowledge of the utility systems and will liaison with facility engineers. All practitioners should know who those individuals are because they need to be called for advice and help in a failure situation.
Beyond the need for inclusion of this topic in future American anesthesia textbooks, awareness now by anesthesia professionals of the underlying mechanisms involved will help in both preventing and dealing with total electrical power failure in the OR. The applicable Joint Commission 2006 Sentinel Event Alert10 is incisive and valuable. It references all the relevant source documents and resources, emphasizes extensive testing of the emergency generator backup power system (beyond the customary 30 minutes per month), and outlines how to create and deploy emergency contingency action plans for all concerned. Risk reduction strategies include detailed planning of and communication about all construction and maintenance projects that could have any effect on the electrical power supply, extra redundancy in backup systems, and meticulous record keeping and analysis. Involved, thoughtful anesthesia professionals can forward printed and/or e-copies of the Joint Commission Sentinel Event Alert (and also this editorial, for that matter) to facility administrators and engineers with a prominent note: “Are we up to date with all these critically important advisories and are we following these protocols?” Doing that not only demonstrates awareness, insight, and caring but might also help prevent a dangerous electrical power failure in your OR—and, thus, along with learning from the experience of Carpenter and Robinson, will help you avoid the need to write the next case report of an OR power failure.
1. Carpenter T, Robinson ST. Response to a partial power failure in the operating room. Anesth Analg 2010;110:1644–6
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7. Atlee JL. Complications in Anesthesia. 2nd ed. Philadelphia: Saunders/Elsevier, 2007
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10. The Joint Commission. Sentinel Event Alert, Issue 37. Preventing adverse events caused by emergency electrical power system failures, September 6, 2006. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_37.htm
. Accessed November 5, 2009