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Correspondence  |   September 2003
Critical Incident with Narkomed 6000 Anesthesia System
Author Affiliations & Notes
  • Andrew G. Usher, M.B., Ch.B.
    *
  • *University of Alberta Hospital, Edmonton, Alberta, Canada.
Article Information
Correspondence
Correspondence   |   September 2003
Critical Incident with Narkomed 6000 Anesthesia System
Anesthesiology 9 2003, Vol.99, 762. doi:
Anesthesiology 9 2003, Vol.99, 762. doi:
To the Editor:—
We would like to report an incident with a Narkomed 6000 Anesthesia System (Draeger Medical, Inc., Telford, PA). An attendant was cleaning an unoccupied operating room when she witnessed a loud “bang,” followed by sparks coming from the bottom of the anesthesia machine. At the time of the noise, the attendant had been adjusting the position of the machine, which was connected to the electrical and gas mains supply but was switched off. The charge nurse, on arrival at the scene, noted smoke in the room. The machine was immediately disconnected from the electrical and gas mains supply, and the problem subsided.
Subsequent analysis showed that a high-impedance short circuit had occurred between the metal can of a capacitor and traces on a printed circuit board in the power supply (Fig. 1). The power supply is located under the main body of the anesthesia machine, and there was minimal flammable material in the immediate area. The engineer's report concluded the incident was due to an intrinsic design fault and was not caused by cleaning solution that had been used to clean the floor prior to the incident. The manufacturer has implemented design changes and replaced the power supplies of all affected machines in Canada and the United States, and the event has been reported to the appropriate health authorities. The manufacturer noted that had the event occurred during use, the anesthesiologist could have disconnected the machine from the main supply with the operation continuing on battery backup, although we would choose to immediately replace the machine, given the unknown status of the internal components.
Fig. 1. Power supply circuit board showing location of short circuit.
Fig. 1. Power supply circuit board showing location of short circuit.
Fig. 1. Power supply circuit board showing location of short circuit.
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Until recently, reports of operating room fires and explosions caused by anesthesia equipment were usually attributable to flammable or explosive anesthetic agents 1 or to contamination of pressurized gas systems with dust or oil. 2,3 The development of sophisticated electronics in anesthesia machines has been associated with occasional reports of malfunctions and one previous report of an electrical fire. 4 This event is an important reminder of the risks that modern anesthesia equipment may bring to the operating room. Prompt reporting of critical incidents allows the rapid investigation and implementation of design improvements to this equipment.
References
Macdonald AG: A short history of fires and explosions caused by anaesthetic agents. Br J Anaesth 1994; 72: 710–22Macdonald, AG
Macdonald AG: A brief historical review of non-anaesthetic causes of fires and explosions in the operating room. Br J Anaesth 1994; 73: 847–56Macdonald, AG
Webb AI, Warren RG, Ackroyd RE: Anesthetic machine explosion. A nesthesiology 1982; 57: 343–5Webb, AI Warren, RG Ackroyd, RE
Rogers S, Davies MW: My anaesthetic machine's on fire. Anaesthesia 1997; 52: 505Rogers, S Davies, MW
Fig. 1. Power supply circuit board showing location of short circuit.
Fig. 1. Power supply circuit board showing location of short circuit.
Fig. 1. Power supply circuit board showing location of short circuit.
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