OJAnes  Vol.5 No.11 , November 2015
Forearm Loss Caused by Automated Non-Invasive Blood Pressure Cuff Malfunction: A Hearsay Report
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.
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.

[1]   Kam, P.C.A., Kavanaugh, R. and Young, F.F.Y. (2001) The Arterial Tourniquet: Pathophysiological Consequences and Anesthetic Implications. Anaesthesia, 56, 534-545.

[2]   Schroeder, B., Barbeito, A., Bar-Yosef, S. and Mark, J.B. (2014) Cardiovascular Monitoring. Chap 45. Miller’s Anesthesia. In: Miller, R.D., Ed., 8th Edition, 1349.

[3]   Spacelabs Healthcare Service Discontinuation Notification (2009) Support of Spacelabs Healthcare Patient Monitoring Products. 1-2.

[4]   Celoria, G., Dawson, J.A. and Teres, D. (1987) Compartment Syndrome in a Patient Monitored with an Automated Blood Pressure Cuff. Journal of Clinical Monitoring, 3, 139-141.

[5]   Sutin, K.M., Longaker, M.T., Wahlander, S., Kasabian, A.K. and Capan, L.M. (1996) Acute Biceps Compartment Syndrome Associated with the Use of a Noninvasive Blood Pressure Monitor. Anesthesia & Analgesia, 83, 1345-1346.

[6]   Srinivasan, C. and Kuppuswamy, B. (2012) Rhabdomyolysis Complicating Non-Invasive Blood Pressure Measurement. Indian Journal of Anaesthesia, 56, 428-430.

[7]   Lee, J.A., Jeon, Y.S., Jung, H.S., Kim, H.G. and Kim, Y.S. (2010) Acute Compartment Syndrome of the Forearm and Hand in a Patient of Spine Surgery—A Case Report. Korean Journal of Anesthesiology, 59, 53-55.

[8]   Spacelabs Healthcare, LLC. Spacelabs Ultraview SLTM Operations Manual 070-1150-01, Rev. AB. Sect 16-16, 260.

[9]   Phillips USA (2015) Phillips Instructions for Use Intellivue Patient Monitor MP20/30, MP40/50, MP60/70/80/90. Release K with Software Revision K.2x.xx Patient Monitoring, 223.

[10]   Charuluxananan, S., Punjasawadwong, Y., Suraseranivongse, S., Srisawasdi, S., Kyokong, O., Chinachoti, T., Chanchayanon, T., Rungreungvanich, M., Thienthong, S., Sirinan, C. and Rodanant, O. (2005) The Thai Anesthesia Incidents Study (THAI Study) of Anesthetic Outcomes: II. Anesthetic Profiles and Adverse Events. Journal of the Medical Association of Thailand, 88, S14-S29.

[11]   Talve, M. (2013) Blood Pressure Cuff Malfunction Causes Crush Syndrome.

[12]   Wu, A.W. and Steckelberg, R.C. (2012) Medical Error, Incident Investigation and the Second Victim: Doing Better but Feeling Worse? BMJ Quality & Safety, 21, 267-270.

[13]   Sari, A.B.A., Sheldon, T.A., Cracknell, A. and Turnbull, A. (2007) Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review. BMJ, 334, 79.

[14]   Dipaola, R.S. and Gallo, M.A. (2008) Hearsay Medicine Is Not Evidence-Based Medicine. Clinical Cancer Research, 14, 337-338.

[15]   Coleman, A.H. (1965) The Hearsay Evidence Rule and the Physician. Journal of the National Medical Association, 57, 256-257.

[16]   Watkins, S.C. and Swidler, A. (2009) Hearsay Ethnography: Conversational Journals as a Method for Studying Culture in Action. Poetics (Amst), 37, 162-184.

[17]   Lee, L.A. and Domino, K.B. (2002) The Closed Claims Project. Has It Influenced Anesthetic Practice and Outcome? Anesthesiology Clinics North America, 20, 485-501.

[18]   Reason, J. (2000) Human Error: Models and Management. BMJ, 320, 768-770.