It was initially reported that the gas sensor has given inaccurate readings.In the course of investigation, this assumption could be denied.Based on the available information and the logfile analysis, a leakage between the water trap and the sensor unit behind it was the root cause.In case of such leakage, the patient gas is diluted with room are leading to the patient gas readings displayed lower than actual ones.As further reported, the user found the water trap not being pushed in properly and that the plastic arms that secure the water trap seemed very loose in the connection with the anaesthetic machine.The user reportedly resolved the issue by replacing the water trap.The instructions for use describe to hold the water trap at the fluted grips and insert it into the holder until it audibly clicks into place.The integrated patient gas monitoring ensures that deviations from set/expected parameters are obvious for the user and that alarms are given according to the set alarm limits.Neither ventilation nor gas dosage will be affected as gas readings are not used for control purpose.The user can derive the patient status from other vital parameters as well.Finally, based on the given information, it could be concluded that the reported issue was caused by a use error namely the water trap not being inserted in the specified way leading to a leakage and thus lower gas readings.
|