The hospital reported that, during a case, mechanical ventilation stopped.The unit reportedly alarmed for a leak.The clinician reportedly switched to manual mode, tried to manually ventilate the pt, but was not successful.Cpr was performed and the pt reportedly recovered.
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Ge healthcare service representative performed a checkout of the equipment.The equipment was checked and found to function within manufacturer's specifications.The logs were downloaded and forwarded to the manufacturing site for analysis.The logs were reviewed and found to contain multiple entries consistent with a patient ventilation leak.According to the hospital, the leak was resolved following reintubation of the patient.The reported details of the event, a review of the logs, and the proper ventilation being achieved after the successful reintubation of the patient are all consistent with a patient breathing system leak at the intubation interface with the patient.A preoperative checkout of the equipment, such as contained in the aisys cs2 user reference manual, is designed to pick up such a leak condition.
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