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5 results

  • Chapter 20 - Common and Uncommon Disasters during Cardiopulmonary Bypass

  • Edited by Florian Falter, Albert C. Perrino, Jr, Robert A. Baker
  • Book:
    Cardiopulmonary Bypass
    Published online:
    24 October 2022
    Print publication:
    10 November 2022, pp 194-204

  • Summary

    Cardiopulmonary bypass (CPB) is highly technical and complex and accident and error can occur due to malfunction of equipment and/or human factors.Since its first successful clinical use in 1953, incremental improvements in the heart lung machine have resulted in a decline of perfusion related accidents. Safety practices have been demonstrated to reduce the incidence of error and equipment fault and need to be constantly reviewed and their implementation should be regularly rehearsed by all members of the intraoperative team and not only by the perfusion team. Institutional protocols, compliance with instructions for use of equipment and step-by-step processes to deal with error and unforeseen events will minimize their impact.

  • Computed tomography scanning of implanted hypoglossal nerve stimulators and approach to device malfunction: case series

  • M J Urban, A Calder, M Jhaveri, P LoSavio
  • Journal:
    The Journal of Laryngology & Otology / Volume 137 / Issue 2 / February 2023
    Published online by Cambridge University Press:
    13 December 2021, pp. 231-236
    Print publication:
    February 2023
    • Article
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  • Objective

    Serious device-related complications for hypoglossal nerve stimulators are rare, but surgeons should implement a prompt and systematic approach to quickly troubleshoot a non-functioning device.

    Method

    Records were queried at a single academic tertiary referral centre between January 2019 and June 2021.

    Results

    The authors present four cases of non-functioning hypoglossal nerve stimulator devices: one case in which migration of the stimulation lead required a revision implantation, one in which the implantable pulse generator was found to be non-functional intra-operatively, one case of an intramuscular sensory lead tract causing pain and one case of implantable pulse generator failure that was probably triggered by implantable cardiac device discharge. In this study, computed tomography imaging was critical to the diagnosis for the first and third cases.

    Conclusion

    Given the limited complication reporting available for hypoglossal nerve stimulators, these cases highlight management and unique imaging findings. The authors present an algorithm to work-up non-functioning hypoglossal nerve stimulator devices.

  • A database system for the registration of complications and failures in cochlear implant surgery applied to over 1000 implantations performed in Nijmegen, The Netherlands

  • H J Theunisse, J J Mulder, R J E Pennings, H P M Kunst, E A M Mylanus
  • Journal:
    The Journal of Laryngology & Otology / Volume 128 / Issue 11 / November 2014
    Published online by Cambridge University Press:
    02 October 2014, pp. 952-957
    Print publication:
    November 2014
  • Objective:

    To create a system for the uniform registration and classification of complications and failures in cochlear implant surgery, and apply it to all the patients who underwent implantation in our clinic.

    Method:

    The definition of a medical complication was established, and data for all cochlear implantations performed between 1987 and 2012 were entered into a custom-made database system.

    Results:

    One or more medical complications were registered in 19.0 per cent of 1003 cochlear implantations. The incidence of ‘hard failure’ was 2.3 per cent. Findings revealed a decrease in device failures over the years; the rate of medical complications remained constant.

    Conclusion:

    Our database system, which is available free of charge, enables fast and accurate data entry. There were a relatively high number of (minor) complications in our series, but comparison with the relevant literature is difficult. This emphasises the need for a uniform definition of ‘complication’ as it relates to cochlear implant surgery, and an appropriate classification system for such complications.

  • Oxygen delivery failure resulting from interference with a Bain breathing system

  • H. Hay
  • Journal:
    European Journal of Anaesthesiology / Volume 17 / Issue 9 / September 2000
    Published online by Cambridge University Press:
    16 August 2006, pp. 591-593
    Print publication:
    September 2000

  • A critical incident is described where the expiratory (scavenging) port of an obsolete version of a Bain-type breathing system valve assembly was inadvertently connected to the common gas outlet of an anaesthetic machine. This resulted in the patient being deprived of a supply of fresh gas. This misconnection was made possible by adding a plastic connector to the valve scavenging port and subsequent wrongful misconnection. The patient fortunately suffered no harm. The case highlights the danger of equipment that has been subjected to unauthorized interference.

  • Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube

  • H. Hay
  • Journal:
    European Journal of Anaesthesiology / Volume 17 / Issue 7 / July 2000
    Published online by Cambridge University Press:
    16 August 2006, pp. 456-458
    Print publication:
    July 2000

  • The delivery of an hypoxic gas mixture to a patient during general anaesthesia is a rare event due to contemporary standards of monitoring, equipment design and alarm features. An incident is described where a split occurred in a rubber seal round the top of a flowmeter control tube. This resulted in a downstream oxygen leak and the delivery of an hypoxic gas mixture to the patient. The bobbin on the oxygen flowmeter did not accurately reflect the amount of oxygen being delivered. A paramagnetic oxygen analyser and a fuel cell oxygen electrode indicated that the inspired oxygen concentration was lower than intended. The anaesthetic machine was exchanged, and the operation continued uneventfully. The faulty anaesthetic machine subsequently passed a formal pressure test by the hospital engineers and also close examination of the flowmeter control valves. The importance of monitoring equipment and the interpretation of the information that they provide is emphasized.