Mini-epidemic of erroneous central venous pressure measurements resulting from the malproduction of a specific part of a pressure transducer system

Anesthesiology. 2009 Jun;110(6):1417-8; discussion 1418-9. doi: 10.1097/ALN.0b013e3181a5ce3e.

Abstract

Electromanometric blood pressure measurements are routine in critically ill patients, and many interventions are based on correct measurements. We report a mini-epidemic of erroneous central venous pressure measurements due to faulty pressure transducer manufacturing resulting in wrong therapeutic decisions.

Publication types

  • Case Reports

MeSH terms

  • Blood Pressure Determination / instrumentation*
  • Cardiac Surgical Procedures
  • Central Venous Pressure / physiology*
  • Disease Outbreaks
  • Equipment Failure
  • Humans
  • Monitoring, Intraoperative / instrumentation*
  • Transducers