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.
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…