Sir,
We would like to report an incident regarding medical gas pipeline pressure and anaesthesia machine checklist. Anaesthesia workstation is the basic necessity for providing anaesthesia. The anaesthesia machine has evolved from the basic gas delivery system of the past to the current advanced workstations. Problems with anaesthesia workstations account for about one-third of equipment problems during anaesthesia.[1] Use of checklists (manual and/or electronic) helps in identifying and reducing the risks that arise due to anaesthesia workstation-related errors.
Failure of the anaesthesia workstation in the intraoperative period is not only an anaesthesiologists' nightmare but also puts the patient's life at risk. A safe anaesthetic is provided in the perioperative period with the early identification of errors in equipment and workstation with the help of various checklists and inbuilt alarms.
We report an incident, where there was activation of a medium priority alarm in all the anaesthesia workstations in an operating room complex. During routine automated anaesthesia workstation checking in the morning, a medium priority alarm was activated in five anaesthesia workstations (4 GE™ Avance CS2™ and a GE™ Avance™) with a display of “Set Alt O2 flow, check agent setting.” All the anaesthesia workstations did not allow any further workstation checks and only alternate O2 source was functioning. When referring to the user's reference manual of the workstation, it was mentioned that there were multiple causes for the error and it suggested contacting a trained service representative.
The service engineers found that before activation of the alarm in all the anaesthesia workstations, there was an error message of oxygen pressure being low from the workstation log. On checking the O2 pressure in the pipeline, it was found to be normal 55 Psi,[2] but the pressure in the medical air and nitrous oxide pipeline was high (65–70 Psi), which is well above the normal range. The pressure of the medical air and nitrous oxide was reduced to normal range and the anaesthesia workstations start passing their automated checks. It was found out that the high pressures in both the pipelines were due to manual error.
Our institution also has few other older anaesthesia workstations which passed the test without any issue during this episode. There were no patient-related adverse events.
In conclusion, this particular episode reaffirms us that modern anaesthesia workstations equipped with better sensors and alarms help us in identifying and reducing the complications. It also places great emphasis on routine pre-anaesthetic workstation checking.
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Conflicts of interest
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REFERENCES
- 1.Fasting S, Gisvold SE. Equipment problems during anaesthesia – Are they a quality problem? Br J Anaesth. 2002;89:825–31. doi: 10.1093/bja/aef276. [DOI] [PubMed] [Google Scholar]
- 2.Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5th ed. New Delhi: Wolters Kluwer, Lippincott Williams & Wilkins; 2011. Medical gas pipeline systems; pp. 26–51. [Google Scholar]