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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. Uneventful iv induction and oral ETT Ventilator on, O2/N2O/Desflurane/fentanyl No NMB at request of surgeon

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Clinical Conference 15 Dec 04

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  1. Clinical Conference 15 Dec 04 George P. Topulos, M.D. Department of Anesthesia and Perioperative Medicine Brigham & Women’s Hospital

  2. Case Presentation - 1 Uneventful iv induction and oral ETT Ventilator on, O2/N2O/Desflurane/fentanyl No NMB at request of surgeon Patient movement and BP, Desflurane 60 yof o/w well - breast lumpectomy and axillary node mapping Several minutes go by Reservoir bag is collapsed No alarms (I think) What would you do now?

  3. 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?

  4. 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?

  5. Recognize Temporize How bad is it? Mechanism Context Best guess at Diagnosis Re-evaluate Diagnosis Specific Therapy Evaluate Success of Therapy Clinical Problem Solving

  6. Crisis Management - 1 Assign someone to take care of the patient and nothing else! They ignore the equipment problem.

  7. Show Simulator Movie

  8. Crisis Management - 2 Don’t ignore it either. “It would be unthinkably awful if this were true so it must not be real.” Don’t panic – do not stare at the anesthesia machine. 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.

  9. 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.

  10. Causes of Circuit Leaks Involve Patient NG tube Cuff leak ETT out Lung leak Do Not involve Patient Circuit disconnect CO2 canister Vaporizer leak

  11. OR Biomedical Engineering Machine Post-MortumJim Philip and OR Biomed TeamPage 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?

  12. SelectaTec® Mounting Control Dial Release Vaporizer is out of circuit until switched on That is why cannot be used below the first marking Selectatec Manifold Vaporizer-specific innards

  13. SelectaTec® Mounting

  14. SelectaTec® Mounting Vaporizer leak will be missed during pre-use checkUnless it is turned on Loose vaporizer will leak at connectionOnly when it is switched on Misalignment of Vaporizer will cause the leak observedAny anterior or posterior movement will do thisAlignment peg creates correct alignment

  15. Vaporizer misaligned Purposeful misalignment

  16. Big Leak only when switched on

  17. Vaporizer off and misaligned Purposeful misalignment

  18. No leak detected

  19. Followup Manufacturer (Draeger) informed of “Failure of Pre-use Check” Understood to be interaction of SelectaTec Vaporizers and back bar withDraeger “No Fresh Gas Hose” design Resolution by Manufacturer? Resolution at BWHInspect vaporizer mounting Perform additional or primary leak testWith desired Vaporizer on

  20. Black Slide

  21. What is wrong with this picture? MRT case cryoablation of kidney tumor.

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