title: Anesthetic vaporizer mount malfunction resulting in oxygenation failure after initiating cardiopulmonary bypass: specific recommendations for the pre-bypass checklist.
abstract: Modern technologic advances in medicine have allowed commonly used machines to perform safely with very low risk and a high degree of success. To detect or prevent potential malfunctions, professionals routinely perform pre-use checks for equipment such as anesthesia machines and cardiopulmonary bypass (CPB) machines. These machine checklists are not only critical for a safe operation but also have large impacts on outcomes. For example, when malfunctions are encountered that could have potential negative ramifications or adverse outcomes, multi-approach strategies should be used to identify rectifiable causes and find solutions that are practical. This information can be used to promulgate safe practice guidelines. This case report identifies a machine-based contributing factor to precipitous hypoxia on initiation of bypass in one of our patients. After a detailed approach to identify preventable root causes, we made simple additions to our pre-bypass checklist and recommend these changes to other institutions.
authors.affiliation: Section of Cardiothoracic Anesthesiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas 72211, USA. gautamnischalk@uams.edu
authors.forename: Nischal K
authors.initials: NK
authors.lastname: Gautam
authors.forename: Michael L
authors.initials: ML
authors.lastname: Schmitz
authors.forename: Luis M
authors.initials: LM
authors.lastname: Zabala
authors.forename: Michael W
authors.initials: MW
authors.lastname: White
authors.forename: Wesley A
authors.initials: WA
authors.lastname: Mckamie
authors.forename: Alyssa
authors.initials: A
authors.lastname: Lutz
authors.forename: Charles E
authors.initials: CE
authors.lastname: Johnson
mesh_terms: D002315:Cardiopulmonary Bypass / Q000295:instrumentation* / Q000592:standards*; D004868:Equipment Failure; D006801:Humans; D007223:Infant; D007431:Intraoperative Complications; D011785:Quality Assurance, Health Care; D017751:Safety Management