Abstract
Failure of an automated blood pressure cuff to deflate when a patient is under general anesthesia can lead to catastrophic consequences if unnoticed for more than three hours [1]. We present this as a hearsay case in which an automated blood pressure cuff of the Spacelabs Ultraview Clinical Workstation monitor (model No. 90385) applied pressure for about five hours resulting in limb thrombosis. In order to analyze this catastrophe, simulation scenarios were tested to elucidate the possible errors and malfunctions that may have led to this injury. We present the analysis of the advantages and validity of the hearsay case report. We also include our proposed criteria that should be required when a hearsay case is considered for publication.
Highlights
The malfunction of an automated non-invasive blood pressure monitor (NIBP) which caused the cuff to remain inflated for greater than five hours caused the loss of an arm below the level of the cuff
While compartment syndrome is a recognized complication of NIBP monitoring [2], the initial question is how this malfunction could go unnoticed by the experienced anesthesiologist who was caring for the patient
We believe there are important safety issues which still place patients at risk four years after the incident; we present it as hearsay case to alert anesthesiologists of the potential adverse situation that may occur
Summary
The malfunction of an automated non-invasive blood pressure monitor (NIBP) which caused the cuff to remain inflated for greater than five hours caused the loss of an arm below the level of the cuff. While compartment syndrome is a recognized complication of NIBP monitoring [2], the initial question is how this malfunction could go unnoticed by the experienced anesthesiologist who was caring for the patient. (2015) Forearm Loss Caused by Automated Non-Invasive Blood Pressure Cuff Malfunction: A Hearsay Report. The “venous stasis” (VS) setting in the NIBP menu on the Spacelabs monitor model 90385 inflates the cuff for two minutes. The malfunction of a venous compression pressure cuff may lead to catastrophic results that may be not apparent to the anesthesiology caretakers. We believe there are important safety issues which still place patients at risk four years after the incident; we present it as hearsay case to alert anesthesiologists of the potential adverse situation that may occur
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