BfArM, the German Federal Institute for Drugs and Medical Devices, has become aware of risk reports in which patients have been harmed as part of anesthesia induction.
Risk of Possible Errors in Connecting Breathing Hoses
In some cases, errors in connecting the breathing hoses, which were not recognized as such or delayed and thus prevented a ventilation of the patient could be identified as the cause. BfArM published a joint recommendation with the German Society for Anaesthesiology and Intensive Care Medicine (DGAI) at the end of January 2019 (Joint Recommendation of the Federal Institute for Drugs and Medical Devices (BfArM) and the German Society for Anaesthesiology and Intensive Care Medicine (DGAI) on anesthesia incidents due to incorrect connection of breathing tubes).
Recommendations for Risk Minimization
Configurations of the ventilation hoses, which prevent misconnection were discussed as constructive solutions. If disposable ventilation hoses are used, BfArM recommends using only those hoses that are glued to the Y-piece and water traps so that faulty connection of the individual legs can be ruled out. If reusable tubing is used, it should be designed and installed in such a way that it is impossible to confuse the expiratory and the inspiratory tubing. On the long run, internationally standardized solutions should be developed in this regard.
In the case of patient damage reported to BfArM, an alternative ventilation source (e.g. manual ventilation bag) was used too late. This fallback level is a central step in the DGAI recommended procedures and algorithms for ventilation situations with leakage or stenotic symptoms. These algorithms should be an elementary component of anesthesiological training and should also be practiced regularly in clinical practice as part of simulation training. BfArM also sees the awareness of the users as very important for the topic and is in exchange with the DGAI.