Hasty C-arm Positioning: A Recipe for Disaster

Abstract

To the Editor: We report here an inadvertent activation of the operating table (Skyton 3100; John Cudia & Associates, Morgan Hill, CA) tilt by a C-arm operated by a surgeon. An anesthetized and paralyzed patient was placed in the left lateral position for a neurosurgical procedure. Before the patient could be appropriately secured, the surgeon moved the C-arm into position over the operating room table. Unbeknownst to all concerned, the bottom end of the C-arm (i.e., the part of the C arm closest to the floor) wedged onto the floor control of the Skyton operating table. This resulted in the continuous activation of the table into a full left lateral tilt. The patient was prevented from falling from the table by nursing staff and a surgical resident who held him with outstretched arms. With the table tilting uncontrollably for no apparent reason, the operating room table was unplugged. This stopped the movement but the patient was still at a 30°-40° tilt. However, the base of the C-arm was now seen on top of the Skytron floor control. The C-arm was removed and the operating room table was again plugged into the electrical outlet. The operating room table control was now able to function correctly and the patient was uneventfully tilted back into a supine position using the control. We bring this case to the attention of your readership as a potential disaster that can occur when floor controls are in close proximity to a maneuvering C-arm. John G. Brock-Utne, MD, PhD Patrick Bolton, MD Gina Marie Zisook, RN Stanford University Medical Center, Stanford, CA, [email protected]