EBME Forums Forums Management Medical Equipment Management One to share - Humidifiers - Fire risk

This was forwarded to me (in a slightly different format), from our SCBU Matron, thought the EBME community might like to know about this - certainly one to be aware of.

"You may have already upgraded all your cables, but thought you should be aware.......................

I would be grateful if you would cascade information about a serious incident that occurred on PICU at Alder Hey yesterday (full investigation on-going) to all relevant people if your unit uses Fisher-Paykel humidifiers & intersurgical circuits.

Alder Hey use the Evita XL ventilator with a Fisher-Paykel humidifier but use intersurgical circuits (inspiratory limb heated) to keep costs down.

Yesterday we had a fire following a spark from one of the wires on the humidifier/vent circuit when the ventilator was being used for a patient in 100% oxygen (having just transitioned from HFOV). The source of the spark is uncertain but it seemed to come from the humidifier.

The fire was apparently like a lit oil rig fire in intensity being driven by 100% oxygen.

Thankfully due to a rapid response by the bedside nurse & rest of the PICU team, no-one was hurt, & the fire was put out ASAP.

Preliminary investigations have revealed that the wire from the humidifier to the heater coil for the inspiratory limb has been upgraded by Fisher-Paykel to prevent surges in current & possibly therefore potential fire risk (from sparks etc). The reason for the upgrade in the cable had not been made clear to our Biomedical Engineering department & all the humidifier cables had not been changed (they will be as soon as new cables arrive).

Please be aware that we are sharing this to prevent similar incidents in other departments. The full cause of this incident is under investigation & these are just our preliminary thoughts - but we felt it important that others were aware of the potential fire hazard".

Hello

Can you tell us or find out the model of Fisher Paykel and the part number of the lead (is it differnet from the previous one?).

Lee

..or take some picture and post in gallery.

Static!

In other words:- maybe it wasn't the kit, after all.

Please don't shoot the messenger.
Dot,(lovely lady) in the Biomedical Engineering department At Alder Hey Advises :
Cannot give any details as this is under investigation by the MHRA & Fisher Paykel, that'll be Doug McKiver & Colin Murray.
I'm sure the findings will become known in due course.