Transcript Clinical Conference 15 Dec 04

Clinical Conference 15 Dec 04
George P. Topulos, M.D.
Department of Anesthesia and Perioperative Medicine
Brigham & Women’s Hospital
Case Presentation - 1
60 yof o/w well - breast lumpectomy and axillary node mapping
Uneventful iv induction and oral ETT
Ventilator on, O2/N2O/Desflurane/fentanyl
No NMB at request of surgeon
Patient movement and BP, Desflurane
Several minutes go by
Reservoir bag is collapsed
No alarms (I think)
What would you do now?
Case Presentation - 2
Switch to bag (manual) ventilation
Unable to ventilate or fill reservoir bag despite O2 FGF up to max.
What would you do now?
Call for help
Wake up patient and cancel surgery?
Case Presentation - 3
Switch to manual resuscitator (ambu bag) for ventilation
Connect to O2 and capnograph!
Patient starts to move around
Total iv anesthesia
What if you could not find manual resuscitator?
What would you do now?
Clinical Problem Solving
Recognize
Temporize
Mechanism
How bad is it?
Context
Best guess at Diagnosis
Specific Therapy
Evaluate Success of Therapy
Re-evaluate
Diagnosis
Crisis Management - 1
Assign someone to take
care of the patient and
nothing else!
They ignore the equipment problem.
Show Simulator Movie
Crisis Management - 2
Don’t panic – do not stare at the anesthesia machine.
Don’t ignore it either. “It would be unthinkably awful if this
were true so it must not be real.”
While you are thinking have the nurse call your staff and say you
want them NOW. This is no time for YOU to be on the phone.
Do not fixate on a single measurement or monitor look at the
other vital signs.
Look at the patient and the surgical field.
Make sure you have not forgotten something you did.
Life is not a multiple-choice test, do all of this in 30 seconds.
Case Presentation - 4
Unable to find leak, clinical engineers, another attending who
happened in.
Automatic "leak test" OK (and was before case).
Disconnect from patient and still a big circuit leak.
Switch anesthesia machines?
If so how when and with what help? if could not get another
anesthesia machine use an ICU vent and iv anesthesia.
Causes of Circuit Leaks
Involve Patient
NG tube
Cuff leak
ETT out
Lung leak
Do Not involve Patient
Circuit disconnect
CO2 canister
Vaporizer leak
OR Biomedical Engineering
Machine Post-Mortum
Jim Philip and OR Biomed Team
Page 3-1055 or call 3-1987
Vaporizer - worked without problem on another
Fabius
Another Vaporizer in same slot created leak on this
Fabius
No leak with Vaporizer off
Big leak with Vaporizer on
Why?
What happens when the Vaporizer is turned on?
SelectaTec® Mounting
Vaporizer is out of circuit until switched on
That is why cannot be used below the first marking
Control
Dial
Selectatec Release
Manifold
Vaporizer-specific innards
SelectaTec® Mounting
SelectaTec® Mounting
Vaporizer leak will be missed during pre-use check
Unless it is turned on
Loose vaporizer will leak at connection
Only when it is switched on
Misalignment of Vaporizer will cause the leak
observed
Any anterior or posterior movement will do this
Alignment peg creates correct alignment
Vaporizer misaligned
Purposeful
misalignment
Big Leak only when switched on
Vaporizer off and misaligned
Purposeful
misalignment
No leak detected
Followup
Manufacturer (Draeger) informed of
“Failure of Pre-use Check”
Understood to be interaction of
SelectaTec Vaporizers and back bar with
Draeger “No Fresh Gas Hose” design
Resolution by Manufacturer
?
Resolution at BWH
Inspect vaporizer mounting
Perform additional or primary leak test
With desired Vaporizer on
Black Slide
What is wrong with this picture?
MRT case cryoablation of kidney tumor.