The hospital reported a patient experienced awareness while under anesthesia during a left mastectomy and axillary clearance.The patient was given propofol, midazolam, and sevoflurane.The hospital reports that after the event, the patient is in good health and there are no further reports of distress from awareness.The patient was offered and accepted a psychologist referral.Ge healthcare's investigation into the reported occurrence is ongoing.
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The o2 concentration, total flow, and anesthetic agent settings in use during the case are unknown, and the customer does not report evidence (e.G.Device alarms or bis entropy values) from during the procedure that there was insufficient anesthetic agent being delivered.This device was used for cases both before and after this event with no reported issues regarding light anesthesia.Therefore, the root cause of the patient awareness reported after the case cannot be determined, though the leak in the o2 flowtube due to a missing part after repair by a non-ge hospital engineer is a potential contributor.The hospital engineer did not perform post-service checkout as instructed by the technical reference manual and the user did not perform pre-use checkout, which would have alerted the user to a leak prior to patient use.
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