The Australian Incident Monitoring Study. Problems with ventilation: an analysis of 2000 incident reports

Abstract

A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched "on" and in 6 because of a failure to detect the disconnection). Failure of detection was usually with ventilator bellows descending in expiration. Complete failure to ventilate occurred in 143 incidents, most commonly because of a disconnection. Disconnection was associated, in one-third of the cases, with interference to the anaesthetic circuit by a third party and in nearly half with surgery on the head and neck. Leaks affected ventilation in 129 incidents, but in only 19 was ventilation totally lost; leaks associated with seal failure of the absorber were common. Misconnections occurred in 36 incidents, most commonly involving the scavenging system. The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists' policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.