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LETTER TO EDITOR
Year : 2014  |  Volume : 8  |  Issue : 3  |  Page : 416-417  

Hazard notice; improper connections and damaged outer tube in oxygen humidifier


1 Department of Anaesthesiology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
2 Department of Periodontology, Rural Dental College, Loni, Maharashtra, India

Date of Web Publication17-Oct-2014

Correspondence Address:
Akshaya N Shetti
Department of Anaesthesiology and Critical Care, Pravara Institute of Medical Sciences, Loni, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.143177

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How to cite this article:
Shetti AN, Kadam AB, Bhatkhande SJ, Mustilwar RG. Hazard notice; improper connections and damaged outer tube in oxygen humidifier. Anesth Essays Res 2014;8:416-7

How to cite this URL:
Shetti AN, Kadam AB, Bhatkhande SJ, Mustilwar RG. Hazard notice; improper connections and damaged outer tube in oxygen humidifier. Anesth Essays Res [serial online] 2014 [cited 2021 May 8];8:416-7. Available from: https://www.aeronline.org/text.asp?2014/8/3/416/143177

Sir,

Oxygen has an important role, while treating critically ill patients and also while anesthetizing. One of the modes of delivery of oxygen is by humidification due to its various advantages. [1] Different techniques developed to improve the humidification, but such gadgets are not free from human errors, while using it. In anesthesia practice most of the human errors are commonly seen, while drug administration. [2] Absence of adequate knowledge of proper usage of equipment or negligence is most common cause for such errors. It can be avoided by proper checking of equipment and training. [3] It is also important to note that manufacturing and supply of good quality product in medical field is essential. Here, we report three case scenarios that we observed and highlight the possible cause of errors and help readers to prevent such mishaps.

Scenario 1: [Figure 1] shows the bobbin of the flow meter was set to desired level, but absence of bubbles formation in the humidifying chamber in spite of adequate distilled water in the chamber. We initially thought that oxygen was not delivered to the patient and hence reassessed the equipment. We could find that the oxygen was delivered to the patient without humidification. With the close look, we could identify that inner tube in the humidifying chamber was disconnected. This was due to loose connection of inner tube, which was accidentally disconnected from the entry port. After proper fixation of inner tube the bubbles started reappearing indicating oxygen getting humidified.
Figure 1: Upper arrow showing set level of O2 flow, lower arrow showing disconnected inner tube of humidifying chamber and absence of bubbles

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Scenario 2: A patient who was getting humidified oxygen complained of suffocation; also, saturation was not improving to the expected level. When the supply of oxygen checked we could identify improper fixation of humidifying chamber to the oxygen flow meter [Figure 2]. Even though, the oxygen was humidified, it was leaking into the atmosphere due to improper fixation. The trainee didn't fix humidifying chamber properly after filling it with distilled water. The patient was comfortable and saturation improved after proper fixation of humidifying chamber.
Figure 2: Improper fixation of humidifying chamber

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Scenario 3: During preanesthesia machine check, while checking oxygen humidifier we identified the damaged part of the outer tube of flow meter. The plastic material of outer tube of flow meter continuously got damaged and particles of it got accumulated over the bobbin [Figure 3]a and b. If we neglected this there could be blocking of inner tube of flow meter after some duration by such particles and bobbin could have not functioned properly. This could be due to low quality production of flow meter tubes.
Figure 3: (a) Plastic particles over the bobbin. (b) Accumulated plastic particles

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The key message here is human errors are not uncommon in anesthesia practice and not restricted to the drug injection. The errors related to equipment are becoming common due to lack of adequate knowledge of health care provider or supply of low quality medical equipments. One should be careful in supplementing humidified oxygen and always have high index of suspicion of possible equipment error if pulse oximeter shows lesser than expected readings or patient complaining of suffocation. The preanesthesia machine check should include oxygen humidifier to avoid such unexpected problems. It is also important to make manufacturer to maintain standard quality-of-life saving medical equipments.

 
   References Top

1.
McIntyre JW. Anesthesia equipment malfunction: Origins and clinical recognition. Can Med Assoc J 1979;120:931-4.  Back to cited text no. 1
    
2.
Cooper L, DiGiovanni N, Schultz L, Taylor AM, Nossaman B. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth 2012;59:562-70.  Back to cited text no. 2
    
3.
Shetti AN, Dhulkhed VK, Roshansingh D, Khyadi S. Mechanical errors in oxygen humidifier. Saudi J Anaesth 2014;8:302-3.  Back to cited text no. 3
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  [Figure 1], [Figure 2], [Figure 3]



 

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