Department of Anesthesiology, University of Virginia, Charlottesville, 22908-0710, USA.
Anesth Analg. 2012 Jan;114(1):144-6. doi: 10.1213/ANE.0b013e3182312c70. Epub 2011 Sep 29.
We report a complete internal fresh gas flow disconnect within a Dräger Fabius GS anesthesia machine without any alarms being triggered. This was undetected primarily because of an incomplete machine checkout in which the step of ensuring proper gas flows by using a "test lung" was omitted. Machine-specific factors, however, also contributed to prevent diagnosis: (1) the machine passed its leak test because the flowmeter bobbin (i.e., floating ball) sealed the flowmeter when back pressure was applied; (2) the mechanical ventilator entrains room air, thus functioning in the absence of fresh gas flow; and (3) the electronic flow sensors functioned "appropriately" because the leak was downstream. Despite the advent of highly automated machines, manual checkout procedures remain crucial to minimizing undiagnosed failures.
我们报告了在没有任何警报触发的情况下，一台德尔格 Fabius GS 麻醉机完全内部新鲜气流断开的情况。这主要是因为机器检查不完整，省略了使用“测试肺”来确保气体流量正常的步骤，因此没有被发现。然而，机器的特定因素也阻碍了诊断：（1）由于流量表的浮子（即浮球）在施加背压时密封了流量表，机器通过了泄漏测试；（2）机械呼吸机吸入室内空气，因此在没有新鲜气流的情况下也能正常工作；（3）电子流量传感器“正常”工作，因为泄漏发生在下游。尽管高度自动化的机器已经问世，但手动检查程序仍然是最小化未诊断故障的关键。
