Description of Event or Problem · 1
WE HAVE WORKED WITH MAQUET CORP. TO ATTEMPT TO CORRECT A SERIOUS PT'S SAFETY ISSUE. THE SERVO I VENTILATOR IN THE ADULT POPULATION HAS SHOWN TO HAVE A PROBLEM WITH DELIVERED PEEP WHEN HUMIDIFIED AIR IS USED IN THE BREATHING CIRCUIT. WE HAVE TRIED SEVERAL FILTERS, AND THE NEW UPGRADED EXPIRATORY CASSETTE THAT WAS RECOMMENDED BY MAQUET. WE TRIED EXTENDING THE DRYING TIME OF THE CASSETTE, AND USED ADDED POSITIONS IN THE DRYER TO HELP THE CASSETTE DRY OUT. OVER THE PAST SEVERAL MONTHS, WE HAVE FOUND 15 PTS ON THIS VENTILATOR THAT THE SET PEEP AND MEASURED PEEP WAS NOT WITHIN A + OR - 2 CMH2O RANGE. WE REMOVED ALL OF THESE FROM PT USE AND HAD THE INSIDE OF THE VENTILATOR CHECKED BY BIOMED. WE FOUND WATER HAD ACCUMULATED IN THE SMALL TUBING INSIDE THE VENTILATOR THAT CONNECTS TO THE INTERNAL PRESSURE TRANSDUCER. THIS WATER CAUSES A BACK PRESSURE THAT WHEN THE VENTILATOR SELF CALIBRATES RESULTS IN THE BASELINE PRESSURE BECOMING POSITIVE AND THE PEEP DELIVERED TO PT BEING REDUCED. OVER 6 MONTHS WE HAVE TRIED ALL STEPS SUGGESTED BY MAQUET. NOTHING HAS RESULTED IN THIS BEING CORRECTED. DUE TO THE NEED TO ASSURE, PEEP LEVELS ARE CORRECT FOR OXYGENATION CONCERNS IN PTS THIS RISES TO A SERIOUS SAFETY ISSUE. OUR FINAL ACTION ON THIS HAS BEEN TO USE THIS VENTILATOR IN THE ADULT POPULATION WITHOUT ACTIVE HUMIDIFICATION. WE WILL USE HME'S ONLY WITH THIS VENT. IT SHOULD BE NOTED THAT WE DO NOT SEE THIS OCCURRING IN THE NEWBORN OR PEDI ICU'S ONLY IN THE ADULT ICU'S. THIS DOES NOT HAPPEN ON ALL PTS ALL THE TIME, BUT WE COULD NOT FIND ANY TRENDS THAT WE COULD SEE A LEADING TO THIS. THIS LEADS US TO CONCLUDE THAT THE LARGER VOLUME OF AIR ON THE ADULT POPULATION IS A FACTOR IN THIS AS WELL. WE BELIEVE THIS IS A DESIGN ISSUE WITH THE EXPIRATORY CASSETTE AND INTERNAL PRESSURE TRANSDUCER SYSTEM. WE HAVE 15 OF THESE.