A medical device alert has been issued by the Medicines and Healthcare Regulatory Agency in the UK for an anaesthetic machine. The Auxiliary Common Gas Outlet (ACGO) has been incorrectly set. The accidental, incorrect setting of the ACGO will result in no fresh gas flow to a patient. Furthermore, if the circle breathing circuit is incorrectly attached to the ACGO, this may result in patient barotrauma.
The anaesthetic machine was manufactured by GE Healthcare. Theatre staff involved in the set up and use of these machines and anaesthetic staff have been advised of the problem with the settings. The MHRA have requested all users to ensure that:
- The position of the ACGO lever and breathing circuit connections are checked before the start of every case, as recommended by the manufacturers. Care is especially recommended for paediatric patients where breathing circuits are changed routinely between patients.
- Relevant members of staff have been fully trained in the use of these anaesthetic machines and are aware of the manufacturer’s training guidance produced in collaboration with the safety committee of the AAGBI.
