The hospital reported a patient connected to an avance cs2 had a sudden drop in blood pressure at 5:58.Resuscitation measures were given.At 6:00, it was determined that the bellows of the avance cs2 were not being supplied with air.The avance cs2 was restarted, normal ventilation resumed, and patient recovered.Ge healthcare will submit a follow-up report when the investigation has been completed.
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The root cause is undetermined, because there is no evidence of device malfunction, and it is unknown whether the device contributed to the patients drop in blood pressure.The device logs show that the system checkout was bypassed prior to the case, and after the reported incident, the case continued for 9 hours.The logs also show that the bellows collapsed at 6:00am, 2 minutes after the reported time of the occurrence.Further, the logs reveal no alarms/errors 10 minutes prior to the blood pressure drop.Due to the machine functioning normally for the rest of the case without any maintenance noted in the complaint or seen in the device logs, the most likely scenario is that there was a leak or disconnect in the patient breathing circuit which caused the bellows to collapse.The patients blood pressure likely dropped due to their poor condition during surgery, the sedation drugs given, and/or a leak in the breathing system.
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