DEVELOPING GUIDANCE

FOR THE MANAGEMENT OF

INTRAOPERATIVE
ANAESTHETIC MACHINE
FAILURE
• Journal of Perioperative Practice 2023, Vol. 33(7-8) 217–222
• Benjamin Milne
• Department of Anesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust,
London, UK
• King’s College London, London, UK
• Kate Prior
• King’s College Hospital NHS Foundation Trust, London, UK
• also affiliated to Department of Anesthesia & Pain Medicine, King’s College Hospital NHS
Foundation Trust, London, UK
 INTRODUCTION
• Intraoperative anesthetic machine failure is an emergency requiring urgent
management to avoid serious risk of harm to the patient, such as
hypoxemia and accidental awareness under general anesthesia.

• In the emergency event of machine failure once a patient is anaesthetized,

and during surgery, identification of the exact site and nature of the fault is
a secondary priority after ensuring the safety of the patient, by
maintaining oxygen delivery and alternative anesthesia.
Machine failure can be:

• Dysfunction of the entire machine

• Constituent elements
• Vaporizer
• Oxygen Delivery Failure
• Failure of Mechanical Ventilator
• Failure of Monitoring devices.
• One registry study of patient safety reports found 1029 cases of anaesthetic
equipment issues over a two-year reporting period.
• Of these, 26.4% involved monitoring issues (8.9% were failure of monitoring
during anesthesia),
• 17.9% were ventilator problems (including sudden failure during anaesthesia in
13.8%)
• other reported issues including dysfunction of gas monitoring (13.4%)
• vaporizer problems (5.1%)
• alarm failure (1.4%).
• Approximately 10% of these incidents were felt to involve harm to the
patient (Cassidy et al 2011).
• Under-reporting is almost certain to have occurred in this cohort (Smith
et al 2006)
• another study has suggested that the anesthetic machine was the
commonest cause of all equipment problems in anesthesia (31%) (Fasting
& Gisvold 2002).
• Establishing a true denominator for these cases has thus far proved elusive
However, there is no consensus guidance for management of intraoperative
anaesthetic machine failure within the United Kingdom, despite the
extensive arsenal of single-sheet guidelines available for the management of
emergencies in anaesthesia, much of which is provided by the Association of
Anaesthetists
 Guideline development
• The guideline was developed using a multi-disciplinary approach, with
input from the wider perioperative team.
• Consideration was given to local reports of machine failure
• Including the issues that arose, and the strengths and weaknesses of the
management strategies employed, as well as the evidence in the
subsequent section.
 Purpose
We aimed to develop guidance for the management of intraoperative
machine failure, based upon a prepared team-based response, for use within
our large teaching hospital.
 Content and rationale
• Calling for help early is a key tenet of these principles, and in line with the
management of all anesthesia-based critical incidents.
• Role assignment is crucial.
• Anesthetist nurse/ODP should seek the alternative equipment.
 Oxygenation
• For maintenance of oxygenation, the most crucial priority, we have
advised use of a self-inflating bag for oxygenation of pt.
 Role Of Second Anesthetist
• A second anaesthetist should be prepared to draw up and administer
propofol, or an ODP/anaesthetic nurse under instruction, depending upon
hospital policy relating to medicine management in an emergency.

• Similarly, the secondary anaesthetist’s familiarity with infusion pumps

makes them the most appropriate to set these up.
 Midazolam ???
Administration of midazolam produces anterograde amnesia, but does not
appear to produce, even immediate, retrograde amnesia (Bulach et al 2005).
Therefore, while midazolam administration may not prevent episodes of
accidental awareness from an established failure in the delivery of
anaesthetic agent, it may provide protection against further anaesthesia
insufficiency during emergency administration of propofol by manual bolus
or attainment of adequate plasma concentration during institution of
infusion.
 Availability Of Monitors
• Maintenance of adequate patient monitoring is a crucial responsibility
(Klein et al 2021), and if able to do so, the main monitor should be used.
• If not, a portable monitor should be available, and be retrieved by staff
members, who should be familiar with its location.
 Implementation
• For the initial implementation of our guidance, we chose day surgery
• Requires 1:1 consultant anesthetist to trainee supervision.
• Successful implementation of any patient safety intervention must account
for the
• Skill and competencies of the individual
• Effective team work
• Clinical environment
• Implementation should be a joint effort of the whole perioperative team, including
anesthetists, ODPs and anesthetic nurses, specialist theatre nursing staff, and clinical
engineering staff

• At our institution, we have implemented the use of laminated guideline posters, within
the anaesthetic area of each theatre.

• Further processes of implementation are made possible with this guideline, including
in situ simulation training, which has become a vital part of health care education

• While not all trainees will experience the same opportunities to manage all real-life
intraoperative emergencies, simulation can ensure that there is homogeneity in skill
acquisition and maintenance (Waldrop et al 2009)
 Limitations
• Not all aspects can be applied to a limited resource hospital
• 1:1 trainee to consultant ratio
• Trained staff
• Backup ventilators and monitors
 Conclusion
We have developed guidance for the management of intraoperative
anaesthetic machine failure. The guidance is aimed to standardise practice,
particularly for less experienced anaesthesia staff, and to ensure ongoing
high-quality patient care in the immediate aftermath of machine failure, but
also following initial management.
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