One of your trainees transfers an intubated patient from your resuscitation room to radiology for a CT scan. They are using a Dräger Oxylog® 3000 to ventilate the patient.Following completion of the CT scan, and prior to transfer back to the emergency department, the ventilator alarm was silenced due to a high Paw alarm.
On arrival back in the ER the nursing staff note oxygen saturations of 88% and rapidly falling…
- The patient was disconnected from the ventilator.
- Using BVM the patient was easily ventilated and oxygen saturations rapidly returned to 100%
- There were no adverse sequele.
- QA review revealed an interesting and potentially worrying alarm system on the Oxylog® 3000.
- If you have an Oxylog® 3000 or Oxylog® 3000 PLUS then try this…
- Turn ventilator on
- Press alarm silence.
- Disconnect oxygen
- There is no breakthrough alarm for this catastrophic failure.
If you silence the alarm for any reason and there is subsequent oxygen supply failure within the next 2 minutes you will have no audible alarm.
Unlike other ventilators on the market the Oxylog® 3000 cannot ventilate without an oxygen supply.
This issue has been raised with Dräger but they have elected not to perform a software upgrade as they don’t see the need to offer a breakthrough alarm system for this potentially lethal fault…
- LITFL: Borrow the Oxylog 3000
- LITFL: Own the Oxylog 3000
- EMCrit.org: Dominating the Vent Part 1 and Dominating the Vent Part 2
- EM Updates: Emergency Department Intubation Checklist v13
- Connolly EM: Oxylog 3000 Plus Overview
- Pulmonary Puzzle 012: Man versus machine: can you deal with post-intubation hypoxia?
- Pulmonary Puzzle 013: Bronchospastic blood pressure badness: what about post-intubation hypotension in an asthmatic?
- Pulmonary Puzzle 014: Alarmingly high pressures: what to do when a high pressure alarm goes off? Which pressures are important?