Anesthetic vaporizer mount malfunction resulting in oxygenation failure after initiating cardiopulmonary bypass: specific recommendations for the pre-bypass checklist.

Modern technologic advances in medicine have allowed commonly used machines to perform safely with very low risk and a high degree of success. To detect or prevent potential malfunctions, professionals routinely perform pre-use checks for equipment such as anesthesia machines and cardiopulmonary bypass (CPB) machines. These machine checklists are not only critical for a safe operation but also have large impacts on outcomes. For example, when malfunctions are encountered that could have potential negative ramifications or adverse outcomes, multi-approach strategies should be used to identify rectifiable causes and find solutions that are practical. This information can be used to promulgate safe practice guidelines. This case report identifies a machine-based contributing factor to precipitous hypoxia on initiation of bypass in one of our patients. After a detailed approach to identify preventable root causes, we made simple additions to our pre-bypass checklist and recommend these changes to other institutions.