To the Editor:
Over a period of 2 weeks, in 4 different operating rooms, 4 monitors attached to 4 different Aisys Datex-Ohmeda anesthestia machines (General Electric, USA) went blank while in use. A burning smell was noticed in each case by the attending anesthesiologist. A portable monitor was hastily replaced in each case. Fortunately, no harm came to the patients.
The Aisys machines, 7 in total, were bought, from General Electric, USA, 2 1/2 years previously. Unfortunately, the supplied transformers had an incorrect rating. The 3 ampere fitted transformer was unable to power the larger 15-inch screen and burned out.
All 7 machines had the faulty 3 ampere transformers removed and replaced with new 5 ampere transformers. The machines have worked well ever since.
There are over 100 Aisys machines in South Africa that have not presented any problems. These machines use a smaller 12-inch screen that is powered by the patient monitor rack via the on-board UPS. battery supply back up. No external supply is used.
We bring these cases to your readers’ attention for the following reasons:
- It is imperative that new machines coming from “overseas” are up to the electrical standards of the recipient country. Both the supplier and the local hospital bioengineering department have a responsibility regarding this. As far as we know this is the first documented case of this problem.
- This may not be an isolated incident. It may have happened before and may not have been reported.
Alan Hold, MB, FFA
Durban, South Africa
John G Brock-Utne, MD, PhD
Stanford University Medical Center
Stanford, California, USA