Episode #182 Rapid Response: Electronic Interference and Anesthesia Machine Malfunction, PART 1
December 27, 2023Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast will be an exciting journey towards improved anesthesia patient safety.
This is a Rapid Response two-part series. Our first featured article is “Electronic Interference Between the Blink Twitchview™ and Medtronic Situate™ Detection System X” by Jerome Lax from the October 2023 APSF Newsletter.
This article highlights electronic interference between these two devices:
- Radiofrequency detection wand (Medtronic Situate™ Detection System X, New Haven, CT )
- Twitchview™ train of four monitoring device (Blink® Device Company, Seattle, WA).
Thank you to Jerome Lax and Justin Hulvershorn for contributing to the article and the show today.
Our second featured Rapid Response Article from the October 2023 APSF Newsletter is, “Recurrent Intraoperative Anesthesia Machine Malfunctions” by David Corpman and Linda Liu.
Thank you to David Corpman for contributing to the show today.
Here is the article from our archives that we discuss on the show today. It is from the Spring 2008 APSF Newsletter. It is “New Guidelines Available for Pre-Anesthesia Checkout” by Jeffrey Feldman; Michael Olympio; Donald Martin; Adam Striker.
Here are the requirements for safe delivery of anesthesia care:
- Reliable delivery of oxygen at any appropriate concentration up to 100%.
- Reliable means of positive pressure ventilation.
- Backup ventilation equipment available and functioning.
- Controlled release of positive pressure in the breathing circuit.
- Anesthesia vapor delivery (if intended as part of the anesthetic plan).
- Adequate suction.
- Means to conform to standards for patient monitoring.
Here are the recommended essential steps in a Pre-anesthesia Checkout Procedure that need to be completed daily or after a machine is moved, serviced, or the vaporizers are changed:
- Verify Auxiliary Oxygen Cylinder and Manual Ventilation Device (Ambu Bag) are Available & Functioning
- Verify patient suction is adequate to clear the airway
- Turn on anesthesia delivery system and confirm that ac power is available
- Verify availability of required monitors, including alarms.
- Verify that pressure is adequate on the spare oxygen cylinder mounted on the anesthesia machine.
- Verify that the piped gas pressures are ≥ 50 psi.
- Verify that vaporizers are adequately filled and, if applicable, that the filler ports are tightly closed.
- Verify that there are no leaks in the gas supply lines between the flowmeters and the common gas outlet.
- Test scavenging system function.
- Calibrate, or verify calibration of, the oxygen monitor and check the low oxygen alarm.
- Verify carbon dioxide absorbent is fresh and not exhausted.
- Perform breathing system pressure and leak testing
- Verify that gas flows properly through the breathing circuit during both inspiration and exhalation.
- Document completion of checkout procedures
- Confirm ventilator settings and evaluate readiness to deliver anesthesia care. (ANESTHESIA TIME OUT)
Here are the recommended essential steps that need to be completed prior to each procedure including between cases:
- Verify patient suction is adequate to clear the airway.
- Verify availability of required monitors, including alarms.
- Verify that vaporizers are adequately filled and if applicable that the filler ports are tightly closed.
- Verify carbon dioxide absorbent is not exhausted.
- Breathing system pressure and leak testing.
- Verify that gas flows properly through the breathing circuit during both inspiration and exhalation.
- Document completion of checkout procedures.
- Confirm ventilator settings and evaluate readiness to deliver anesthesia care. (ANESTHESIA TIME OUT)
Be sure to tune in next week for Part 2!
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© 2023, The Anesthesia Patient Safety Foundation
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Today, we are exploring the Rapid Response to Questions From Our Readers section of the October 2023 APSF Newsletter. This column is a great way to facilitate communication of technology-related safety concerns raised by our readers who are using the technology equipment and manufacturers and industry representatives. Our topics today include electronic interference in the operating room and recurrent anesthesia machine malfunctions.
Before we dive into the episode today, we’d like to recognize Masimo, a major corporate supporter of APSF. Masimo has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Masimo – we wouldn’t be able to do all that we do without you!”
Our first featured article is “Electronic Interference Between the Blink Twitchview™ and Medtronic Situate™ Detection System X” by Jerome Lax. To follow along with us, head over to APSF.org and click on the Newsletter Heading. First one down is the current is the current issue. From here, scroll down until you get to the Rapid Response section and our featured article. You can also find all of the Rapid Response articles under the Newsletter heading and the third one down is Rapid Response to Questions from our Readers. And don’t worry, I will include a link in the show notes as well.
Before we get into the article, let’s meet the author. I will let him introduce himself now.
[Lax] “Hello, my name is Jerome Lax and I’m a clinical professor of anesthesiology in the Department of Anesthesiology, preoperative Care and Pain Medicine at NYU Langone Health in Manhattan, New York.”
[Bechtel] Thank you to Lax for contributing this important question and to our show today. Let’s take a listen now.
[Lax] “Dear Rapid response, recently at our institution, toward the end of a laparotomy, a puzzling event occurred as a radio frequency detection wand made by Medtronic called the situation detection System X was waved over the abdomen. An electronic interference alert was triggered. Subsequent assessment of the operating room environment revealed that the source of the interference was the Twitch view train of four monitoring device manufactured by the Blink Device Company, Seattle, Washington.
We ascertain that the Medtronic detection system display will read scan obstruction if the wand is positioned within four feet of Twitch view. We also discovered that this interference is eliminated by disconnecting the Twitch U device from its AC Power source. This is achieved either by unplugging its power cord from the wall socket, or removing the device from its cradle.
While the actions mentioned above may be a temporary fix to this issue, we have approached both manufacturers with an eye towards implementing a more definitive technological solution to this incompatibility.”
[Bechtel] Do you work at an institution with either of these pieces of equipment, the Medtronic radio frequency detection wand or the Blink Device Company Twitch View Train of Four? Have you ever seen this electronic interference? We are going to turn our attention to the response from Justin Hulvershorn, the CEO of Blink Device Company. The TwitchView train of four monitor may be used during surgery and anesthesia care just like other vital signs monitoring equipment. The Situate, the Medtronic Radio Frequency Detection Wand, is a device that may be used at the end of the surgery to make sure that no surgical sponges have been left behind. The TwitchView monitor uses a Qi-certified wireless battery charging system. Qi is a wireless charging standard that was developed by the Wireless Power Consortium and operates between 110-205kHz. This is also used in iPhone and other commercial wireless charging systems. The Medtronic Situate device uses low frequency RFID which also operates on the same frequency band. Blink Device Company tested these devices and confirmed that the “SCAN Obstruction” notification on the Situate was indeed caused by the TwitchView wireless charging system. They were also able to replicate the same “SCAN Obstruction notification” with a wireless iPhone charger. There is no change in the TwitchView function when the Situate device is in use. The team at Blink Device Company agree with the actions taken by Lax, unplugging the TwitchView or unseating the TwitchView monitor from the charging base to pause the wireless charging, during a Situate scan to remove the interference while maintaining function of the TwitchView, which can operate on battery power. At the moment, Blink is evaluating alternate Qi-certified charging systems to see if there is one that is less likely to obstruct the Situate Device scan. Blink is also collaborating with Medtronic to see if there are any additional solutions. An important consideration for designing technology that uses wireless battery charging systems going forward is the possible interaction and challenges for using devices that operate on the same frequency bands.
Thank you so much to Lax and Hulvershorn for contributing to this Rapid Response article. We are really on a roll.
Let’s take a look at the next Rapid Response Article from the October 2023 APSF Newsletter, “Recurrent Intraoperative Anesthesia Machine Malfunctions” by David Corpman and Linda Liu. You can find this article by heading back over to APSF.org and clicking on the Newsletter heading. Third one down is Rapid Response to questions from our readers and then scroll down until you get to our next featured article. I will include the link in the show notes as well.
Here is one of the authors now.
[Corpman] “Hi, my name is David Corpman, and I co-authored this article while a senior anesthesia resident at the University of California, San Francisco.”
[Bechtel] To get things started, I asked Corpman why he wrote the article. Let’s take a listen to what he had to say.
[Corpman] “We wrote this article to describe a series of unexpected intraoperative anesthesia machine malfunctions happening in our fleet. Our standard practice at UCSF is to complete a pre-induction checklist which we attest to in the anesthesia record. However, these standard checks do not detect every possible point of failure, including the loose cables that caused the malfunctions we describe. The anesthesia machines are serviced by biomedical technicians on a set maintenance schedule that is intended to catch and prevent these rare events from occurring as the equipment gradually wears down. However, rare events still occur, and we hope that by sharing our experience, we can reinforce how to respond in the moment and how to work with both biomedical technicians and the manufacturer to further reduce the risk of recurrence.”
[Bechtel] Thank you so much to Corpman for contributing to the show today and don’t worry we will hear from him again.
Intraoperative anesthesia machine malfunction does not happen very often, thankfully, but it may be a big threat to patient safety according to the American Society of Anesthesiologists Closed Claims database. One of the first things that many anesthesia professionals do in the morning is to perform a pre-anesthesia checkout procedure on the anesthesia machine. This can help to decrease machine failure events, but certain failures may not be prevented with a standard checklist. The ASA Committee on Equipment and Facilities initiated a comprehensive anesthesia apparatus checkout procedure recommendation in 2008.
Let’s take a moment to review this now. We are going to jump back into the APSF archives to the article, “New Guidelines Available for Pre-Anesthesia Checkout” by Jeffrey M. Feldman and colleagues. To follow along with us head over to ASPF.org and click on the Newsletter heading. Fourth one down is Newsletter archives. Then scroll down to Spring 2008 and there you will find the article. I will include a link in the show notes as well.
Imagine a scenario where you induce general anesthesia with propofol, then administer an intubating dose of rocuronium. Once the patient loses consciousness and stops spontaneous respiration, you attempt to perform mask ventilation…but you are unable to deliver a positive pressure breath. You look over at your breathing circuit and there is no immediate cause of the problem. This is a critical situation. Can you ventilate the patient before he becomes hypoxic? Do you have an alternative method for ventilation immediately available and functioning? Do you have a reliable source of oxygen? Also, what about your anesthesia machine? Did you perform a pre-anesthesia checkout of the machine prior to providing patient care? How could this happen? Today, performing anesthesia machine checks is part of safe, routine practice. This article provides some important history on the checking the anesthesia equipment before patient use to help decrease the risk for severe postoperative morbidity and mortality. In 1993, the pre-use anesthesia apparatus checkout recommendation was developed, but by 2008 this was not well understood or reliable used by anesthesia professionals. Over time, the anesthesia machines were modified with improved technology so that one checkout procedure could not be applied to every anesthesia machine. This was the background behind the new pre-use anesthesia apparatus checkout recommendation that was developed in 2008 by a task force with representatives from major anesthesia delivery system manufacturers, the American Association of Nurse Anesthetists, the American society of anesthesia technicians and technologist, and the ASA. The goals included to have a procedure that could be applied to all anesthesia delivery systems and that could be reliably performed by anesthesia professionals using the machines on a day-to-day basis. The 2008 Recommendations for Pre-Anesthesia Checkout Procedures includes 15 items. Keep in mind that some of these steps may be part of an automated checkout process on many machines. The time required for beginning of day checklist is usually less than 5 minutes and less than 2 minutes between cases. This is a small amount of time for a large amount of confidence that the anesthesia machine will be working while you provide safe anesthesia care.
Let’s start with the requirements for safe delivery of anesthesia care, which include the following:
- Reliable delivery of oxygen at any appropriate concentration up to 100%.
- Reliable means of positive pressure ventilation.
- Backup ventilation equipment available and functioning.
- Controlled release of positive pressure in the breathing circuit.
- Anesthesia vapor delivery (if intended as part of the anesthetic plan).
- Adequate suction.
- Means to conform to standards for patient monitoring.
Next up, Table 1 in that article covers the recommended essential steps in a Pre-anesthesia Checkout Procedure. Here are the steps that need to be completed daily or after a machine is moved, serviced, or the vaporizers are changed:
- Verify Auxiliary Oxygen Cylinder and Manual Ventilation Device (Ambu Bag) are Available & Functioning
- Verify patient suction is adequate to clear the airway
- Turn on anesthesia delivery system and confirm that ac power is available
- Verify availability of required monitors, including alarms.
- Verify that pressure is adequate on the spare oxygen cylinder mounted on the anesthesia machine.
- Verify that the piped gas pressures are ≥ 50 psi.
- Verify that vaporizers are adequately filled and, if applicable, that the filler ports are tightly closed.
- Verify that there are no leaks in the gas supply lines between the flowmeters and the common gas outlet.
- Test scavenging system function.
- Calibrate, or verify calibration of, the oxygen monitor and check the low oxygen alarm.
- Verify carbon dioxide absorbent is fresh and not exhausted.
- Perform breathing system pressure and leak testing
- Verify that gas flows properly through the breathing circuit during both inspiration and exhalation.
- Document completion of checkout procedures
- Confirm ventilator settings and evaluate readiness to deliver anesthesia care. (ANESTHESIA TIME OUT)
If we turn our attention to Table 2, we can review the recommended essential steps that need to be completed prior to each procedure including between cases:
- Verify patient suction is adequate to clear the airway.
- Verify availability of required monitors, including alarms.
- Verify that vaporizers are adequately filled and if applicable that the filler ports are tightly closed.
- Verify carbon dioxide absorbent is not exhausted.
- Breathing system pressure and leak testing.
- Verify that gas flows properly through the breathing circuit during both inspiration and exhalation.
- Document completion of checkout procedures.
- Confirm ventilator settings and evaluate readiness to deliver anesthesia care. (ANESTHESIA TIME OUT)
Are you and the anesthetic techs working together to complete these essential steps at your institution?
We still need to return to our second featured article, but you will have to tune in next year for the exciting conclusion to our October 2023 Rapid Response segment. But don’t worry, that’s just next week. In the meantime, we hope that all of your anesthesia machine checkout procedures go smoothly as 2023 comes to a close.
If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
If one of your goals for the new year is to learn more about how low-flow anesthesia can deliver safe & effective patient care while decreasing cost & environmental pollution, then, we hope that you will head over the APSF low-flow course. Check out the link in the show notes or head over to our website, apsf.org. Then, click on the Patient Safety Resources heading, 6th one down is APSF Technology Education initiative, then click on Low Flow Anesthesia. The course is free of charge to all anesthesia professionals, but a guest login is required for non-ASA members. There are continuing education credits available for physicians, nurses and anesthesia assistants. For physicians enrolled in the MOCA process, the CME credits are patient safety eligible. Thank you for listening to the Anesthesia Patient Safety Podcast all year We are looking forward to continuing to bring you the latest in perioperative patient safety in 2024.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2023, The Anesthesia Patient Safety Foundation