Education

Case serial: SCH-2021-03
Title: Anesthesia Deepness Brain Monitoring (ABDM) system & ABDM electrode sensor

Description

Patient Condition

  • A 80-year-old female patient with acute cholangitis.
  • The patient was in preparation for general anesthesia.

Events

  • Before starting general anesthesia, the ADBM electrode sensor (the sensor) was applied to the patient’s forehead.
  • The ADBM system failed to display the EEG signal on its monitor.
  • The nurse confirmed that the expiration date of the sensor had not passed.

Post-event management & Health effect

  • The electrode sensor was replaced with another sensor of the same lot and it worked properly.
  • Nurses are experiencing frequent sensor detection errors, especially in older patients. They assume that the skin condition may have an impact, so particular attention is payed when attaching the sensor to elderly patients.

Investigations (Cause, Improvements)

  • The quality manager of the manufacturer received the problematic sensor from the user.
  • When the problematic sensor was tested by connecting it to an ADBM system by the manufacturer, the system detected the signal normally.
  • The quality manager checked the hydro-gel status of other products in the same lot and found that it conformed to the manufacturer's manufacturing standards.

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Annex

Code

#

%

A A01 - Lower Level Codes 19 31.1%
A A07 - Lower Level Codes 5 8.2%
A A26 - Lower Level Codes 5 8.2%
A A12 - Lower Level Codes 5 8.2%
A A22 - Lower Level Codes 4 6.6%
A A11 , A13 , A02 , A04 , A05 , A09 , A03 , A24 , A25 , A17 , A21 , A23 23
total:61
37.7%
B B01 - Lower Level Codes 23 50.0%
B B02 - Lower Level Codes 8 17.4%
B B03 - Lower Level Codes 7 15.2%
B B07 - Lower Level Codes 2 4.3%
B B21 - Lower Level Codes 1 2.2%
B B22 , B04 , B05 , B09 , B14 5
total:46
10.9%
C C19 - Lower Level Codes 12 25.5%
C C01 - Lower Level Codes 6 12.8%
C C02 - Lower Level Codes 6 12.8%
C C23 - Lower Level Codes 4 8.5%
C C14 - Lower Level Codes 3 6.4%
C C03 , C04 , C13 , C16 , C20 , C21 , C05 , C06 , C07 , C09 , C10 16
total:47
34.0%
D D14 - Lower Level Codes 9 23.1%
D D11 - Lower Level Codes 5 12.8%
D D01 - Lower Level Codes 5 12.8%
D D10 - Lower Level Codes 4 10.3%
D D15 - Lower Level Codes 3 7.7%
D D16 , D06 , D08 , D02 , D07 , D13 , D17 , D04 13
total:39
33.3%
E E24 - Lower Level Codes 15 38.5%
E E01 - Lower Level Codes 7 17.9%
E E17 - Lower Level Codes 3 7.7%
E E22 - Lower Level Codes 3 7.7%
E E08 - Lower Level Codes 2 5.1%
E E11 , E21 , E02 , E03 , E04 , E06 , E23 9
total:39
23.1%
F F26 - Lower Level Codes 13 30.2%
F F05 - Lower Level Codes 11 25.6%
F F01 - Lower Level Codes 4 9.3%
F F04 - Lower Level Codes 4 9.3%
F F03 - Lower Level Codes 3 7.0%
F F27 , F02 , F17 , F19 , F25 8
total:43
18.6%
G G02 - Lower Level Codes 9 28.1%
G G03 - Lower Level Codes 8 25.0%
G G07 - Lower Level Codes 6 18.8%
G G01 - Lower Level Codes 4 12.5%
G G04 - Lower Level Codes 2 6.2%
G G05 , G06 3
total:32
9.4%

EEG

Ju min Park , Republic of Korea
[ 2021-09-03 09:21:32.0]

What precautions should be taken in EEG research?

[1]

It's a real case!

Soo Jeong Choi , Republic of Korea
[ 2021-09-04 07:15:08.0]

Frequent case! User education is important.

[1]

Needs improving the usability

You Kyoung Lee , Republic of Korea
[ 2021-09-10 15:37:50.0]

No device problem was found, but the same problem happens, especially in older patients, according to nurse's experiences.
I think the manufacturer needs to consider improving the usability of the device.

[1]

device functionality

María Eugenia Villalobos-Hernández , (Non-APEC) Costa Rica
[ 2021-09-12 02:53:41.0]

In this case the device is working as expected, however in elder patients it was not working at all, so it is necessary to develop more research on the device use to elderly patient's skin conditions, because the situation happened before.

[1]

the gel

Pei-Hsuan Huang , The United States
[ 2021-09-14 04:42:39.0]

the gel should consider different situation

[0]

It was a useful case.

Soohyun Nam , Republic of Korea
[ 2021-09-16 10:15:12.0]

It was a useful case.

[0]

Anesthesia Deepness Brain Monitoring (ABDM) system & ABDM electrode sensor

Stevie Lee , Republic of Korea
[ 2021-09-16 13:43:12.0]

it's useful activity

[0]

About EEG

YoonSung Kim , Republic of Korea
[ 2021-09-16 17:49:11.0]

EEG signal is difficult, but this programe help to study about EEG.

[0]

device functionality in elder patients

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 10:03:57.0]

Because, in elder patients it was not working at all

[1]

device functionality in elder patients

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 10:52:10.0]

Because, in elder patients it was not working at all, more research should be done in older adults

[1]

Patient-Device Interaction Problem

Jieun Lee , Republic of Korea
[ 2021-09-20 21:28:41.0]

There should more research centered on electrode sensors effective for elderly patients, as the majority of patients with neurologic issues, thus requiring an EEG, are the population. Also, I am curious if there was an additional problem to the patient in this particular case, other than the delayed preparation for anesthesia.

[0]

EEG

Citra Bonnita Putri , Indonesia
[ 2021-09-21 00:55:31.0]

The activity is helpful.

[0]

Anesthesia Deepness Brain Monitoring (ABDM) system & ABDM electrode sensor

Regina Li , Hong Kong
[ 2021-09-21 11:19:47.0]

This is a very helpful activity.

[1]

Anesthesia Deepness Brain Monitoring (ABDM) system & ABDM electrode sensor

Seontae Kim , Republic of Korea
[ 2021-09-21 17:56:33.0]

Helpful activity

[0]