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Poorly maintained anesthesia machine associated with awareness under anesthesia

Posted Oct 05 2009 10:03pm

Four hospitals in California were recently fined $25,000 each for serious mistakes resulting in patient harm or death.   Among the incidents was the use of a malfunctioning anesthesia machine which resulted in three patients being partially awake during their surgery.    With respect to the anesthesia machine the California Health and Human services Statement of Deficiencies notes that on 3/28/08 an Anesthesiologist expressed some question about the functionality of the anesthesia machine during a surgical procedure.   The same anesthesia machine was used again on 3/31/08 for three more surgical procedures.”   Source: San Diego Union Tribune, August 16, 2008.   In at least one of the three cases of awareness there were hemodynamic signs suggesting that too little anesthetic drug was being given.   None of the articles commented on the availability of or use of agent analyzers.   Also unclear is why it took 3 cases of awareness on the same day in the same OR before the machine was taken out of service.   It is cases such as these that fuel the national call by some groups and individuals for mandatory use of brain electrical activity monitors during general anesthesia.  As I have noted in past posts, there is considerable difficulty in interpreting and abstracting newspaper articles that deal with legal or potental legal issues.  I may have erred in some of my interpretation.


David S. Smith, M.D., Ph.D. 

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