Anesthesia machines have increasingly become fully electronic and automated integrating monitoring ventilation and anesthetic delivery systems all in one compact machine Gone are the days when an anesthetist was required to manually check each individual vital component of the anesthesia machine step by step This often required considerable amount of time to fully complete the machine checkout The modern anesthesia machine checkout is fully automated and can be completed with a push of a button Some components of an electronic checkout are mandatory and the other optional figure 3 This brief report describes a potentially injurious and unsafe condition associated with optional low pressure leak Low P Leak test in Aisys CS2 anesthesia system Datex Ohmeda Inc GE Healthcare Waukesha WI The Aisys CS2 user s reference manual recommends preoperative optional low P leak test In Aisys CS2 the positive pressure Low P Leak test detects machine leak before the breathing system upstream from the inspiratory valve between the common gas outlet and high pressure pneumatics and includes the gas mixture and the vaporizer It measures low pressure pneumatic leaks of 50 ml The Aisys CS2 user s reference manual describes different method of performing positive pressure Low P Leak test depending on the configuration of the machine i e presence or absence of Auxiliary Common Gas Outlet ACGO In the non ACGO Aisys
CS2 machine the positive pressure Low P Leak test is listed as optional in the electronic checkout menu Once initiated on screen instructions take the operator through 3 step process to complete the test Two different types of leak test adapters figure 1 are available for this purpose In the non ACGO Aisys CS2 system the manufacturer recommends occluding the inspiratory flow sensor outlet with the leak test adapter for performing positive pressure Low P Leak test There are several inherent problems associated with performing positive pressure Low P Leak test using manufacturer provided adapters especially type A brown adapter in the non ACGO Aisys CS2 1 Type A adapter allows operator to attach anesthesia circuit to the outer end of the adapter figure 2 This may not be recognized by the operator at the start of the case and result in an inability to deliver gas to the patient 2 There are no sensors on the machine end of the leak test adapter warning the operator or disabling the Start Case function of the machine The electronic Low P Leak test sequence doesn t provide warning about the hazard of breathing circuit occlusion 3 Start Case function on the electronic display remains active even when the leak test adapter especially type
A figure 2 is attached to the inspiratory flow sensor outlet This can happen if the leak test adapter is attached to the inspiratory flow sensor outlet and Low P Leak test not triggered In this scenario all functions of anesthesia machine except mechanical ventilation remain operational including volume pressure and gas monitoring APL valve bag mode and oxygen flush The operator of the machine is able to adjust the airway pressure using flows and APL valve while squeezing the bag However the leak test adapter does not allow gas delivery from machine to the breathing circuit and the patient due to total occlusion at the inspiratory flow sensor outlet This creates a dangerous situation and potentially lethal crisis and injury to the patient In a hypoxic and hypoventilatory crisis situation anesthesia providers often first focus their attention toward the patient and not immediately recognize machine related problem in this scenario inspiratory flow occlusion by the leak test adapter figure 2 Furthermore when compared with other anesthesia machines the locations of the inspiratory and expiratory flow sensor outlets on Aisys CS2 anesthesia machine are not easily visible hidden under inspiratory and expiratory valve assembly and any attachments at these outlets are not clearly noticed by the operator In summary leak test adapter used for the positive pressure
Low P Leak test on non ACGO Aisys CS2 machine can be associated with potentially lethal injury to the patient by producing total occlusion at the inspiratory flow sensor outlet The lack of Aisys CS2 machine s ability to sense the leak test adapter on the inspiratory flow sensor outlet and absence of warning in the electronic screen instructions during Low P Leak test should prompt anesthesia providers to reconsider this method for testing Low P Leak as part of routine checkout procedure I would like to highlight the fact that this flaw along with hidden position of the flow sensor outlets in Aisys CS2 may be considered potentially unsafe features of this machine and all anesthesia providers who use this machine must be aware of these drawbacks As always backup ventilation equipment Bag valve mask and spare full oxygen tank must be immediately available during all anesthetic administration Figure 1 Two types Type A Brown Type B Green of leak test adapters used to perform positive pressure Low P Leak test in Aisys CS2 Machine
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