[354457]
While a pt was under anesthesia with ulthane (servoflurane) for the insertion of a rigid bronchoscope, the anesthesiologist heard a loud noise described as sounding like a gun shot. The hospital anesthesia team had observed that the rebreathing bag had blown off its attachment on the datex-ohmeda anesthesia machine. The pop-off valve that was partially closed blew off the anesthesia machine and the scavenger hose was blown off its attachment. Flames were present in the lower part of the absorber canister and the loose filled baralyme material appeared to be glowing and flickering. There was the smell of plastic and smoke. The surgeon immediately removed the bronchoscope from the pt and a bag mask unit was attached to the wall outlet and used to ventilate the pt with 100% oxygen. A new anesthesia machine was brought into the operating room and the pt was once again placed under anesthesia with ulthane. The surgeon reinserted the bronchoscope to inspect for injury and no injury was identified. It was determined that the surgical team would continue on to the next phase of the surgical procedure. After continuing to the next phase of surgery (placing of endotracheal tube), the pt developed severe oxygen desaturation and severe bradycardia that required treatment with epinephrine, atropine and chest compressions. The pt recovered after ventilation with 100% oxygen. At this point the procedure was stopped and the pt was moved to the anesthesia recovery unit where the pt successfully recovered from the events. The reporter believed that the events that occurred to the pt were life threatening, though no permanent injury was sustained due to the reported "explosion" of the anesthesia machine. It is believed that the airway difficulties were unrelated to the reported "explosion" of the anesthesia machine.
Patient Sequence No: 1, Text Type: D, B5