Dräger Ventilator - Ventilates Without Fresh Gas Flow

DR BHAVISHA SHAH (Orcid ID : 0000-0002-0445-1998)
Article type : Letter

Accepted Article
Dräger Ventilator - Ventilates without Fresh Gas Flow
1
Bhavisha Shah
1
Kawshala Peiris
1
Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
Dr. B. Shah; Department of Anaesthesia, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1
5WW; 01162586474. Email address: [email protected]
Sir,
We present a case which illustrates a serious design flaw in the Dräger Fabius Tiro anaesthetic ma-
chine, which risks hypoxia and, additionally, awareness in a paralysed patient.
This occurred during anaesthesia in a healthy 2 year old child undergoing emergency trauma surgery
to their hand. Following intravenous induction with Propofol and Alfentanil, tracheal intubation was
performed without a muscle relaxant. A T-piece breathing circuit was used for induction and it was
connected to the common gas outlet (CGO) of the anaesthetic machine. Anaesthesia was maintained
using Sevoflurane.
While performing forearm nerve blocks the T-piece was changed to a circle circuit to mechanically
ventilate the patient who had become apnoeic from the opioid. After the nerve block was completed
which took about 10 minutes, it was noticed that the T-piece was still connected to the CGO with fresh
gas flow (FGF) flowing into the room whilst the circle was connected to the patient’s endotracheal
tube (but not to the CGO) with no fresh gas (oxygen or Sevoflurane) entering the circle.
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/pan.13631
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As illustrated in the diagram, in the Dräger Fabius Tiro machine, the black hose must be connected to
the CGO in order for the circle circuit to be in continuity with the patient. Despite this major oversight,
Accepted Article
the circuit and ventilator had continued to ventilate the patient without alarming to indicate that there
was no FGF in the circle circuit.
Throughout this we had a normal capnograph trace and the patient remained saturated at 95%. There
were also no signs of tachycardia or movement from the patient indicating wake up.
In this situation, we were fixated on the task of performing ultrasound guided nerve blocks and, there-
fore, we failed to appreciate the low MAC value and, unfortunately, the MAC alarm did not alert us to
this. Later, we discovered that as a standard all MAC alarms in anaesthetic rooms are disabled so
that it doesn’t continually alarm at induction while the volatile levels are building up.
Discussion:
We made some interesting findings about the Dräger Fabuis Tiro anaesthetic machine:
- The ‘no FGF’ alarm only sounds if there is zero flow on the flowmeter. As long as there is a
FGF of at least 0.1L/min the ‘no FGF’ alarm is disabled. However, the ventilator will continue
to cycle. Therefore the alarm appears to be independent of the actual ventilator module.
- The piston driven ventilator in the Fabius Tiro works by drawing in room air to fill the ventilator
chamber when there is inadequate FGF turned on. It has several potential places where it
may draw room air in:
1. If the circle is connected to the CGO then the ventilator can fill itself by drawing in
from the reservoir bag. This is often witnessed at the start where the reservoir bag
collapses initially
2. If the CGO and the circle systems are not connected then the negative pressure cre-
ated can draw in room air from the negative pressure relief valve of the ventilator;
3. The open end of the reservoir bag tubing if a bag is not connected;
4. It can also draw room air from the disconnected end of the CGO hose
In this situation we cannot rely on the normal safety alarms to protect the patient.

No FGF alarm in this ventilator model is inactivated if there is flow switched on, however minimal this
may be.
Accepted Article
MAC alarms are disabled on most anaesthetic room monitors.
The low FiO2 alarm is unlikely to be activated if the ventilator is entraining room air unless the default
low limit is set higher than the factory standard of 18%. Obviously, had our patient’s saturations fallen
below 95% we would most likely have investigated and picked up our error sooner.
This potential risk is of particular concern in paediatric anaesthesia which often involves changing
circuits during the conduct of anaesthesia.
We notified Dräger of the incident, particularly as this was unlikely to be an isolated event unique to
our hospital. Dräger informed us that MHRA issued a Field Safety Notice which addresses the issue
of hypoxia but we didn’t feel it addressed the issue of awareness[1].
Hypoxia in this situation has also been acknowledged by Tim Meek [2].
Learning points:
- Having a correctly working and checked anaesthetic machine and circuits are an important aspect
of safety. But it cannot prevent mistakes happening when circuits are switched part way through
anaesthesia.
- Hand ventilating the patient with the circle circuit before switching on the ventilator would alert the
anaesthetist that there was no FGF filling the reservoir bag.
- AA/low MAC alarms to be enabled on the monitors accepting the distraction it is likely to cause un-
til an acceptable MAC is achieved.
ETHICS - no approval required
FUNDING - Not applicable
DISCLOSURES - No conflict of interest

References:
Accepted Article
1. Field Safety Notice: Draeger: Fabius GS/ GS premium/ MRI/ Plus/ Plus XL/ Tiro. October 2017.
Anaesthetic machines & monitors. MHRA reference: 2017/011/001/291/002
2. https://www.aagbi.org/sites/default/files/ANews_Feb_2018_web.pdf
Figure 1

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DR BHAVISHA SHAH (Orcid ID : 0000-0002-0445-1998)

Article type : Letter

5WW; 01162586474. Email address: [email protected]

chine, which risks hypoxia and, additionally, awareness in a paralysed patient.

was no FGF in the circle circuit.

may draw room air in:

This article is protected by copyright. All rights reserved.

circuits during the conduct of anaesthesia.

of hypoxia but we didn’t feel it addressed the issue of awareness[1].

ETHICS - no approval required

FUNDING - Not applicable

DISCLOSURES - No conflict of interest

This article is protected by copyright. All rights reserved.

Anaesthetic machines & monitors. MHRA reference: 2017/011/001/291/002

This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

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