MEDISORB

Description of Event or Problem

DURING THORACIC SURGERY CASE, ANESTHESIOLOGIST ATTEMPTED TO REPLACE USED SODASORB CONTAINER AS PATIENT WAS STARTING TO HAVE INCREASED INSPIRATION OF CARBON DIOXIDE WHICH COULD BE HARMFUL DURING THE SURGERY. CANISTER WAS REPLACED AND COULD NOT VENTILATE OR OXYGENATE PATIENT. CANISTER REMOVED AND FOUND TO BE CRACKED, USED CONTAINER THEN REPLACED UNTIL ANESTHESIA TECH COULD BRING REPLACEMENT CANISTER. MULTIPLE EVENTS HAVE OCCURRED PREVIOUSLY WITH THESE SAME CANISTERS FROM THE SAME MANUFACTURER WHERE THE REPLACEMENT CANISTER HAS A CRACK IN IT, AND IT IS UNSAFE TO CONTINUE TO USE THESE DEFECTIVE DEVICES WHEN WE DEPEND ON THEIR FUNCTIONING APPROPRIATELY IN THE MIDDLE OF SURGERY.