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 OJAnes  Vol.5 No.11 , November 2015
Forearm Loss Caused by Automated Non-Invasive Blood Pressure Cuff Malfunction: A Hearsay Report
Steven M. Shulman1*, Yunseok Namn2, Stanislav Lando3, Patrick Discepola4
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Abstract: Failure of an automated blood pressure cuff to deflate when a patient is under general anesthesia can lead to catastrophic consequences if unnoticed for more than three hours [1]. We present this as a hearsay case in which an automated blood pressure cuff of the Spacelabs Ultraview Clinical Workstation monitor (model No. 90385) applied pressure for about five hours resulting in limb thrombosis. In order to analyze this catastrophe, simulation scenarios were tested to elucidate the possible errors and malfunctions that may have led to this injury. We present the analysis of the advantages and validity of the hearsay case report. We also include our proposed criteria that should be required when a hearsay case is considered for publication.
Keywords: Monitor, Malfunction, Hearsay, Compartment Syndrome, Non-Invasive Blood Pressure
Cite this paper: Shulman, S. , Namn, Y. , Lando, S. and Discepola, P. (2015) Forearm Loss Caused by Automated Non-Invasive Blood Pressure Cuff Malfunction: A Hearsay Report. Open Journal of Anesthesiology, 5, 227-232. doi: 10.4236/ojanes.2015.511041.
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