Circulation 72,683 • Volume 19, No. 4 • Winter 2004   Issue PDF

Turn Your Alarms On!

Ann S. Lofsky, MD

With the advent of sophisticated anesthesia machines incorporating comprehensive monitoring, it is easy to forget that serious anesthesia mishaps still can and do occur.

When patients sustain brain damage or die because of a major error by an anesthesiologist, these cases may properly be termed anesthetic “disasters.” Reviews of recent disastrous cases have revealed many similarities. One striking finding is that most of these cases would probably never have occurred had the anesthesiologist activated and responded to the standard alarms on the pulse oximeter and end-tidal carbon dioxide monitors.

A 23-year-old healthy male presented for a laparoscopic bilateral inguinal hernia repair. It was the first such procedure this hospital had performed, so they decided to film it. It was an uneventful general anesthesia induction, and the patient was paralyzed with atracurium and maintained with isoflurane gas. At some point the anesthesiologist left the head of the bed so that he could watch the procedure on the video monitors and chat with the film crew. When the surgeon paused momentarily to switch sides, the anesthesiologist returned to the head of the bed and announced to everyone that the patient was in cardiopulmonary arrest. Unnoticed, the breathing circuit had become disconnected at the Y-connector under the drapes. All the alarms were flashing on the anesthesia machine, but they had apparently been silenced. This patient sustained severe permanent brain damage.

Many anesthesiologists today do not routinely use esophageal or precordial stethoscopes. If you are not looking directly at the monitors and their alarms have been silenced, you are essentially performing without a net. Frequently, alarms are intentionally silenced at the end of cases to prevent them from false-alarming when patients are disconnected for transport to recovery. Many monitors have alarms that must be manually reactivated at the beginning of a new anesthetic or else they will remain in the silent mode. Failure to perform this step can apparently be a fatal mistake.

A 32-year-old woman had a laparoscopic cholecystectomy performed under general anesthesia. At the surgeon’s request, a plane film x-ray was shot during a cholangiogram. The anesthesiologist stopped the ventilator for the film. The x-ray technician was unable to remove the film because of its position beneath the table. The anesthesiologist attempted to help her, but found it difficult because the gears on the table had jammed. Finally, the x-ray was removed, and the surgical procedure recommenced. At some point, the anesthesiologist glanced at the EKG and noticed severe bradycardia. He realized he had never restarted the ventilator. This patient ultimately expired.

Today’s operating rooms are routinely noisy, activity-filled spaces with plenty of distractions. It is common for people and equipment to move in and out of the OR while music plays and phone calls are answered. Despite our best attempts, no one can expect to remain 100 percent vigilant at all times. Your pulse oximeter and CO2 alarms are your best defenses. Do not neglect them.

A 54-year-old man underwent an open reduction of an ankle fracture under spinal. The patient was spontaneously breathing, but snoring loudly. Toward the end of the case, the spinal appeared to be wearing off, and the patient was quite agitated. The anesthesiologist gave additional fentanyl and midazolam and silenced the pulse oximeter alarm because the patient kept knocking it off and it was alarming. He then went to the foot of the bed to see how much longer the case would be. He became engaged in a discussion with the surgeon while watching him close the incision. When the drapes were removed at the end of the case, the patient was noted to be profoundly cyanotic. There was an agonal rhythm on the EKG. This patient was resuscitated, but he sustained profound brain damage.

Leaving the head of the bed and turning off the pulse oximeter alarm appear to be a particularly dangerous combination. After reviewing cases like these over and over, I personally turn my pulse oximeter alarm on the instant a patient comes into the operating room, and I refuse to turn it off for anything. If it false-alarms because of Bovie or electrical interference, I stand with my finger on the alarm until the interference stops. If you think cases like these could never happen to you, think again. The anesthesiologists involved in the cases above all had good reputations within their hospitals and had never before been sued. Many anesthesiologists are understandably devastated after cases like these, and when interviewed make statements such as: “I just got distracted. It seemed like such a short time.”

For the sake of your patients, your own peace of mind, and your careers—


© 2002 by The Doctors Company
Dr. Lofsky is a member of the Board of Governors and chairperson of the Insurance Committee of The Doctors Company of Napa, CA.