Common faults in resuscitation equipment - Guidelines for checking equipment and drugs used in adult cardiopulmonary resuscitation

Resuscitation

Volumn 55, Issue 2, 2002, Pages 137-149

  Dyson, Elsbeth ^a   Smith, Gary B ^a  

^a QUEEN ALEXANDRA HOSPITAL   (United Kingdom)

Author keywords

Airway management; Cardiopulmonary resuscitation; Defibrillation; Drug therapy; Safety

Indexed keywords

ADRENALIN; AMIODARONE; ATROPINE; BICARBONATE; CALCIUM CHLORIDE; LIDOCAINE;

AIRWAY; BIOFILTER; BOUGIE; CANNULA; CATHETER; CENTRAL VENOUS CATHETER; CIRCULATION; DEFIBRILLATOR; DEVICE; ENDOTRACHEAL TUBE; EQUIPMENT; ERROR; FACE MASK; GLOVE; HEART ARREST; INTUBATION; LARYNGEAL MASK; LARYNGOSCOPE; LONG TERM CARE; MEDICAL INSTRUMENTATION; OROPHARYNX; OXYGEN BREATHING; OXYGEN SUPPLY; PRIORITY JOURNAL; RESUSCITATION; REVIEW; SAFETY; SURGICAL INSTRUMENT; TRACHEOTOMY;

EID: 0036843120     PISSN: 03009572     EISSN: None     Source Type: Journal    
DOI: 10.1016/S0300-9572(02)00169-7     Document Type: Article

References (108)

1. Guidelines for basic life support. A statement by the Basic Life Support Working Party of the European Resuscitation Council, 1992, Resuscitation 1992;24:103-110.
2. Guidelines for advanced life support. A statement by the Advanced Life Support Working Party of the European Resuscitation Council, 1992, Resuscitation 1992;24:111-121.
3. Robertson C., Holmberg S. Compression techniques and blood flow during cardiopulmonary resuscitation. A statement for the Advanced Life Support Working Party of the European Resuscitation Council. Resuscitation. 24:1992;123-132.
4. Robertson C. The precordial thump and cough techniques in advanced life support. A statement for the Advanced Life Support Working Party of the European Resuscitation Council. Resuscitation. 24:1992;133-135.
5. Hapnes S.A., Robertson C. CPR-drug delivery routes and systems. A statement for the Advanced Life Support Working Party of the European Resuscitation Council. Resuscitation. 24:1992;137-142.
6. Koster R., Carli P. Acid-base management. A statement for the Advanced Life Support Working Party of the European Resuscitation Council. Resuscitation. 24:1992;143-146.
7. Lindner K.H., Koster R. Vasopressor drugs during cardiopulmonary resuscitation. A statement for the Advanced Life Support Working Party of the European Resuscitation Council. Resuscitation. 24:1992;147-153.
8. Forms for registration of CPR efforts and outcome, respectively for out-of-hospital and in-hospital cardiac arrest. Prepared by the Working Party on Research Coordination of the European Resuscitation Council, in collaboration with the Cerebral Resuscitation Study Group of the Belgian Society for Emergency and Disaster Medicine and the Working Group on CPR of the European Academy of Anaesthesiology, Resuscitation 1992;24:155-166.
9. Management of peri-arrest arrhythmias. A statement for the Advanced Cardiac Life Support Committee of the European Resuscitation Council, 1994, Resuscitation, 1994;28:151-159.
10. Peri-arrest arrhythmias: Notice of 1st update, Resuscitation 1996;31:281.
11. Baskett PJF. The ethics of resuscitation. A statement by the Chairman of the European Resuscitation Council, 1994. Guidelines for Resuscitation. Belgium: European Resuscitation Council Secretariat, 1994.
12. European Resuscitation Council guidelines for the use of automated external defibrillators by EMS providers and first responders. A statement from the Early Defibrillation Task Force, with contributions from the Working Groups on Basic Advanced Life Support, and approved by the executive committee of the European Resuscitation Council, Resuscitation 1998;37:91-94.
13. Guidelines for the basic management of the airway and ventilation during resuscitation. A statement by the Airway and Ventilation Management Working Group of the European Resuscitation Council, Resuscitation 1996;31:187-200.
14. Guidelines for the advanced management of the airway and ventilation during resuscitation. A statement by the Airway and Ventilation Management Working Group of the European Resuscitation Council, Resuscitation 1996;31:201-230.
15. The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support. A statement from the Working Group on Basic Life Support, and approved by the executive committee of the European Resuscitation Council, Resuscitation 1998;37:67-80.
16. The 1998 European Resuscitation Council guidelines for adult advanced life support. A statement from the Working Group on Advanced Life Support, and approved by the executive committee of the European Resuscitation Council, Resuscitation 1998;37:81-90.
17. European Resuscitation Council guidelines 2000 for adult advanced life support. A statement from the Advanced Life Support Working Group (1) and approved by the Executive Committee of the European Resuscitation Council, Resuscitation 2001;48:211-221.
18. European Resuscitation Council Guidelines 2000 for Automated External Defibrillation. A statement from the Basic Life Support and Automated External Defibrillation Working Group (1) and approved by the Executive Committee of the European Resuscitation Council, Resuscitation 2001;48:207-209.
19. Schein R.M., Hazday N., Pena M., Ruben B.H., Sprung C.L. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 98:1990;1388-1392.
20. Smith A.F., Wood J. Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation. 37:1998;133-137.
21. King D., Davies K.N., Cope C.S., Silas J.H. Survey of cardiac arrests and cardiac arrest trolleys in a district general hospital. Br. J. Clin. Pract. 48:1994;248-250.
22. Morton T., Brady S., Clancy M. Difficult airway equipment in English emergency departments. Anaesthesia. 55:2000;495-498.
23. Nolan T.W. System changes to improve patient safety. Br. Med. J. 320:2000;771-773.
24. Arnstein F. Catalogue of human error. A latent error in the packaging of a Guedel airway. Br. J. Anaesth. 79:1997;645-656.
25. Gordon H.L., Tweedie I.E. Facemask hazard. Anaesthesia. 44:1989;84.
26. Raymond R., Tolley P.M. Oxygen connections to resuscitation equipment. Anaesth. Intensive Care. 20:1992;254.
27. Maxwell D.M. Design hazard of Laerdal masks. CMAJ. 141:1989;70.
28. Binnie N., Janczak J., Wright D. Misassembly of Laerdal masks. Anaesthesia. 45:1990;70.
29. Brain A.I.J. The Intravent Laryngeal Mask. Instruction Manual. 2nd ed. 1993.
30. Squires S.J. Fragmented laryngeal mask airway. Anaesthesia. 47:1992;274.
31. Vickers R., Springer A., Hindmarsh J. Problem with the laryngeal mask airway. Anaesthesia. 47:1992;639.
32. Crawford M., Davidson G. A problem with the laryngeal mask airway. Anaesthesia. 47:1992;76.
33. Boge E., Brandis K. Testing the laryngeal mask. Anaesth. Intensive Care. 23:1995;751.
34. Cameron D., Onslow J. Obstruction of airway equipment. Anaesthesia. 57:2002;188-189.
35. Srikanth K. Yet another foreign body in a laryngeal mask airway. Anaesthesia. 57:2002;189-190.
36. Lipp M., Jaehnichen G., Golecki N., Fecht G., Reichl R., Heeg P. Microbiological, microstructure, and material science examinations of reprocessed combitubes after multiple reuse. Anesth. Analg. 91:2000;693-697.
37. Oczenski W., Krenn H., Dahaba A.A., Binder M., El-Schahawi-Kienzl I., Kohout S., Schwarz S., Fitzgerald R.D. Complications following the use of the combitube, tracheal tube and laryngeal mask airway. Anaesthesia. 54:1999;1161-1165.
38. Vezina D., Lessard M.R., Bussieres J., Topping C., Trepanier C.A. Complications associated with the use of the esophageal-tracheal combitube. Can. J. Anaesth. 45:1998;76-80.
39. Lewer B.M.F., Karim Z., Henderson R.S. Large air leak from an endotracheal tube due to a manufacturing defect. Anesth. Analg. 85:1997;944.
40. Chilvers R., Jenkins J. A hidden leak. Anaesthesia. 50:1995;920.
41. Patel A., Smith M. Tracheal cuff failure. Anaesthesia. 50:1995;568-569.
42. Gettelman T.A., Morris G.N. Endotracheal tube failure: undetected by routine testing. Anesth. Analg. 81:1995;1313.
43. Barst S., Yossefy Y., Lebowitz P. An unusual cause of airway obstruction. Anesth. Analg. 78:1994;195.
44. Palmer J.H.M. Unexpected cause of tracheal cuff failure. Anaesthesia. 48:1993;347-348.
45. Marshall A. Leaking catheter mount swivels. Anaesth. Intensive Care. 28:2000;333.
46. Thomas R. A blocked catheter mount. Anaesthesia. 56:2001;188-189.
47. Gallacher B.P., Kelly M., Mora R.R. Failure to ventilate due to a glass ampule fragment occlusion of the breathing circuit elbow connector. Anesthesiology. 87:1997;180.
48. Thorpe CM. Plastic in anaesthetic circuit, Anaesthesia 2002;57:85-6.
49. Kubota Y., Toyoda Y., Kubto H. Endotracheal intubation assisted with a pencil torch. Anesthesiology. 68:1988;167.
50. Przemeck M., Vangerow B., Panning B. Mini flashlight as a spare light source for a failing fiberoptic laryngoscope. Anesthesiology. 86:1997;1217.
51. Smith M.B., Camp P. Broken laryngoscope. Anaesthesia. 44:1989;179.
52. Vernon J.M. A broken laryngoscope. Anaesthesia. 45:1990;697.
53. Hodges U.M. Damage to a laryngoscope. Anaesthesia. 43:1988;711.
54. Norman P.H., Coveler L.A., Daley M.D., Dugas M.J. Failure of a laryngoscope blade. Anesth. Analg. 86:1998;445-451.
55. Rocco M., Chatwani A., Shupak R. Laryngoscope handle malfunction. Anesthesiology. 65:1986;107.
56. Dorsch J.A., Dorch S.E. Understanding Anaesthesia Equipment. 1984;350 Williams and Wilkins, Baltimore, MD.
57. Esler M.D., Baines L.C., Wilkinson D.J., Langford R.M. Decontamination of laryngoscopes: a survey of national practice. Anaesthesia. 54:1999;587-592.
58. Roberts R.B. Cleaning the laryngoscope blade. Can. J. Anaesth. 20:1973;241-244.
59. Abramson A.L., Gilberto E., Mullooly V., France K., Alperstein P., Isenberg H.D. Microbial adherence to and disinfection of laryngoscopes used in office practice. Laryngoscope. 103:1993;503-508.
60. Phillips R.A., Monaghan W.P. Incidence of visible and occult blood on laryngoscope blades and handles. Am. Assoc. Nurse Anesth. J. 65:1997;241-246.
61. Foweraker J.E. The laryngoscope as a potential source of cross infection. J. Hosp. Infect. 30:1995;315-317.
62. Babb S., Mann S. Disposable laryngoscope blades. Anaesthesia. 57:2002;286-287.
63. Robbins P.M. Critical incident with gum elastic bougie. Anaesth. Intensive Care. 23:1995;654.
64. Latto P. Fracture of the outer varnish layer of a gum elastic bougie. Anaesthesia. 54:1999;492-514.
65. Kumar D.S., Jones G. Is your bougie helping or hindering you? Anaesthesia. 56:2001;1121.
66. Gardner M., Janowski S. Detachment of the tip of a gum elastic bougie. Anaesthesia. 57:2002;88.
67. Cupitt J.M. Microbial contamination of gum elastic bougies. Anaesthesia. 55:2000;466-468.
68. Moyle JTB, Davey A. Ward's Anaesthetic Equipment. 4th ed. Philadelphia, PA: Saunders, 1997, p. 172.
69. Sharma M.L., Bhardwaj N., Chari P. Broken metal intubating stylet. Anaesth. Intensive Care. 22:1994;624.
70. Fishman R.L. Reuse of a disposable stylet with life threatening complications. Anesth. Analg. 72:1991;266.
71. Sullivan M.J.J., Guyatt G.H. Simulated cardiac arrests for monitoring quality of in-hospital resuscitation. Lancet. 2:1986;618-620.
72. Kozak R.J., Ginther B.E., Bean W.S. Difficulties with portable suction equipment used for prehospital advanced airway procedures. Prehosp. Emerg. Care. 1:1997;91-95.
73. McDonald D.S. Blocked Yankauer sucker. Anaesthesia. 51:1996;405-406.
74. Dickinson M.C. A faulty Yankauer suction catheter. Anaesthesia. 57:2002;310.
75. Bussac J.J., Bhudoye R., Borsarelli J. The "high concentration" oxygen mask: a dangerous defect. Ann. Fr. Anesth. Reanim. 8:1989;522.
76. Dubinsky I. Fictitious hypoxia - a result of misconnection of oxygen tubing to a wall source of air. Am. J. Emerg. Med. 10:1992;613-614.
77. Arepalli N, Jones N. Oxygen or air, Anaesthesia 2001;56:1205.
78. Thomas AN, Hurst W, Saha B. Interchangeable oxygen and air connectors, Anaesthesia 2001;56:1205.
79. Poplett N, Dyson E, Smith GB, Problems with mis-assembly of adult manual resuscitators, Resuscitation 2002;53:109-11.
80. Munford B.J., Wishaw K.J. Critical incidents with nonrebreathing valves. Anaesth. Intensive Care. 18:1990;560-574.
81. Ho A.M.H., Shragge B.W., Tittley J.G., Fedoryshyn R.T., Puksa S. Exhalation obstruction due to Laerdal valve misassembly. Crit. Care Med. 24:1996;362-364.
82. Myers D.P., de Leon-Casasola O.A., Bacon D.R., Slowik W.P., Lema M.J. Bilateral pneumothoraces from a malfunctioning resuscitation valve. J. Clin. Anaesth. 5:1993;433-435.
83. Hunter W.A.H., Duthie R.A. Malfunction of Laerdal resuscitator valve. Anaesthesia. 46:1991;505-506.
84. Anonymous, Interchanging Laerdal and solco resuscitators and components, Health Devices 1988.
85. Bleske B.E., Wheatley W.K., Townsend K.A., Guzzardo M.L., Billi J.E., Shea M.J. Drug therapy during cardiac arrest in two hospitals. Am. J. Hosp. Pharm. 50:1993;2538-2545.
86. Avery T. Are your emergency drugs past their expiry date? Prescriber. 9:1998;13.
87. Rudland S.V., Annus T., Dickinson J., et al. Epinephrine degradation in the general practice. Br. J. Gen. Pract. 47:1997;827-828.
88. Aldington D.J. Blocked emergency syringe. Anaesthesia. 57:2002;311-312.
89. Resuscitation Council (UK) . Advanced Life Support Manual. 4th ed. 2001.
90. White R.D. Maintenance of defibrillators in a state of readiness. Ann. Emerg. Med. 22:1993;302-306.
91. The Defibrillator Working Group, Cummins R.O., Chesemore K., White R.D. Defibrillator failures, causes of problems and recommendation for improvement. J. Am. Med. Assoc. 264:1990;1019-1025.
92. Charbonnier F., Crampton R. Standard for defibrillator devices. J. Assoc. Adv. Med. Instrum. 1988.
93. Amoore J.N. Defibrillator batteries: care and testing. Survey of defibrillators at the Royal Infirmary of Edinburgh. Br. J. Intensive Care Suppl. 1994.
94. Emergency Care Research Institute . Hazard: user error and defibrillator discharge failures. Health Devices. 15:1986;340-343.
95. Emergency Care Research Institute . Hazard: main (AC line) power switches on battery-powered equipment. Health Devices. 16:1987;345-346.
96. Mismatch of critical care product R2 181-239 cables and hewlett-packard 43100 defibrillators, Health Devices 1989;18:233.
97. Battery pins on lifepak 5 defibrillator/monitors, Health Devices 1989;18:84-85.
98. Deakin C.D., Petley G.W., Drury N.E., Clewlow F. How often should defibrillation pads be changed? The effect of evaporative drying. Resuscitation. 48:2001;157-162.
99. Deakin CD, Petley GW, Drury NE, Clewlow F. Evidence based guidelines for the use of defibrillation pads, Resuscitation 2001;51:283-6.
100. 3M Healthcare. 3M Defib-Pads. Conductive gel pads for defibrillation or cardioversion, Recommendations contained in packet insert, 1997.
101. Bradbury N., Hyde D., Nolan J. Reliability of ECG monitoring with the gel pad/paddle combination after defibrillation. Resuscitation. 44:2000;203-206.
102. Cleland M.J., Maloney J.P., Rowe B.H. Problems associated with the Z-fold region of defibrillation electrodes. J. Emerg. Med. 16:1998;157-161.
103. Choi P.T., Yip G., Quinonez L.G., Cook D.J. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit. Care Med. 27:1999;200-210.
104. Edwards S.M., Williams J.C., McCahon. Universal precautions at cardiac arrests. Anaesthesia. 56:2001;378.
105. Criss E. Latex allergies. A growing concern for both emergency medical providers and patients. J. Emerg. Med. Serv. 25:2000;42-49.
106. Miller D.M., Youkhana I., Karunaratne W.U., Pearce A. Presence of protein deposits on "cleaned" re-usable anaesthetic equipment. Anaesthesia. 56:2001;1069-1072.
107. Eisenberg M.S., Bergner L., Hallstrom A. Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning. J. Am. Med. Assoc. 241:1979;1905-1907.
108. Spierdijk J, Kooijman J, Bovill JG. Checklist procedures: aviation shows the way to safer anesthesia, Scientific Exhibit, American Society of Anesthesiologists Annual Scientific Meeting Atlanta, Georgia, 1987.