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Sudden blackout of the Dräger Zeus Anaesthetic Machine

Sudden blackout of the Dräger Zeus Anaesthetic Machine. Dr Tse , Yee Wah Dr Koo, Chi Kwan Dr Tan, Song Tuen Dr Chan, Yau Wai Queen Elizabeth Hospital, Hong Kong. Background. Ventilator failure is not an uncommon incident in operating theatres

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Sudden blackout of the Dräger Zeus Anaesthetic Machine

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  1. Sudden blackout of the Dräger Zeus Anaesthetic Machine Dr Tse, Yee Wah Dr Koo, Chi Kwan Dr Tan, Song Tuen Dr Chan, YauWai Queen Elizabeth Hospital, Hong Kong

  2. Background • Ventilator failure is not an uncommon incident in operating theatres • Dräger Zeus Anaesthetic Machine failure: not been reported before

  3. Background TCA(TM) = Target-Controlled Anesthesia automatic control of gas dosages manual control touch screen Drager Zeus Anaesthetic machine

  4. Incident • elective hepatectomy • Dräger Zeus Anaestehtic machine failure: unresponsive touch screen & rebooted subsequently • laid by standby screen • shortly after diathermy usage

  5. Incident • Patient disconnected from ventilator, ventilated by manual resuscitator • Dräger Zeus ventilator was replaced by DrägerNarkomed IV • photos were taken to record the setup layout for later investigation

  6. Incident • Preliminary examination by the Dräger Company: • no external defects or damages • PASS: Self test, gas delivery, ventilatory test • analysis of the device status report: USB port error of the device computer in the ventilator

  7. (1) Power cord of electric blanket & (2) data cable

  8. Postulation • Electrical interference • rebooted shortly after the use of diathermy Where? • Between diathermy & electric blanket (the only device that was plugged to the auxiliary power socket of the ventilator) • data transmission in USB port was affected

  9. Simulation Devices: (1) Dräger Zeus (2) Conmed 6400 (argon beam coagulator) (3) Cusa 200 (ultrasonic surgical aspirator) (4) Force FX (diathermy) (5) KanMed 202W (electric blanket control unit) (6) HP monitor OWON oscilloscope LEM HEME LH240 ammeter

  10. Simulation

  11. (1) Power cord of electric blanket & (2) data cable

  12. Diathermy use on pork

  13. (1) Oscilloscope & (2) Ammeter connected to power cord

  14. To prove the postulation… • Control (no diathermy): no failure • Diathermy in cutting mode: no failure • Diathermy in coagulation mode: FAILURE • without data cable connection: no failure • with use of optical relay: no failure

  15. Discussion – 2 circuits

  16. Discussion • Capacitive coupling • in any eletrosurgery: high frequency current in a conductor can induce current in another conductor separated by an insulator • Conductors: diathermy tip & metal wirings in electric blanket • Insulator: gel pad

  17. Discussion – why coagulation mode? • Why diathermy in coagulation mode?

  18. Discussion

  19. Discussion • without data cable connection: no failure • with use of optical relay: no failure

  20. Solutions • Do not use the auxiliary power socket in the Dräger Zeus • Use of an optical signal relay (to interrupt the passage of electric interference via the USB port of the device computer)

  21. Learning points • Electrical safety is an important issue in OT • Proper connection of each device requires an anesthetist’s attention • any electrical fault can lead to potential/ actual crisis

  22. References • Myerson, K R. Potential hazard of East-Radcliffe ventilator. Failure to entrain adequate oxygen. Anaesthesia. 40(3):285-7, 1985 Mar. • Williams DJ. Ventilator failure due to non-ISO-standard components. [Case Reports. Letter] Anaesthesia. 56(4):392-3, 2001 Apr. • Sosis MB. Drager ventilator failure on changing the respiratory rate setting.[see comment]. [Case Reports. Letter] Anesthesia & Analgesia. 76(2):453-4, 1993 Feb. • Ananthanarayan C. Fisher JA. Drager ventilator failure.[comment]. [Comment. Letter] Anesthesia & Analgesia. 77(3):638, 1993 Sep. • Barahal D. Sims C. Ventilator failure during use of a new anesthesia machine. [Letter] Anesthesiology. 95(2):568-9, 2001 Aug. • Rafael A. Ortega, M.D.,* Bruce Vrooman, M.D., RaniaHito, M.S. Another Cause for Ventilator Failure. Anesthesiology 2006; 104:1351 • Ortega RA. Zambricki ER. Fresh gas decoupling valve failure precludes mechanical ventilation in a DraegerFabius GS anesthesia machine. [Case Reports. Letter] Anesthesia & Analgesia. 104(4):1000; discussion 1000-1, 2007 Apr. • Photo of Dräger Zeus ventilator from http://medgadget.com/archives/2006/04/zeus_anesthesia.html • Photo of electric blanket from User Manual KanmedOperatherm 202 www.kanmed.se/download/download_files/operaterm/op-202-050_vers5_uk.pdf • Haag R. Cuschieri A. Recent advances in high-frequency electrosurgery: development of automated systems. [Review]. Journal of the Royal College of Surgeons of Edinburgh. 38(6):354-64, 1993 Dec. • Force FXTM Electrosurgical Generator Technical Specifications http://www.valleylab.com/product/es/generators/pdf/Lforcefx.pdf (page 4) • Tucker RD. Voyles CR. Laparoscopic electrosurgical complications and their prevention. [Review] [16 refs] [Case Reports. Journal Article. Review] AORN Journal. 62(1):51-3, 55, 58-9 passim; quiz 74-7, 1995 Jul.

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