Awareness under anaesthesia due to a defective gas‐loaded regulator

Puri, Goverdhan D; George, Marilyn; Singh, Harpreet; Batra, Y. K.

doi:10.1111/j.1365-2044.1987.tb04050.x

Cited by 8 publications

(4 citation statements)

References 4 publications

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“…A defective fail-safe gas-loaded regulator resulted in oxygen flow through the N 2 O flowmeter. 3 A similar case of leakage of O 2 through N 2 O flow meter due to faulty O 2 fail safe device was also reported. 4 In this case report, ruptured diaphragm and loose packing in oxygen failure safety valve allowed oxygen to flow through N 2 O flow meter ( Figure 2).…”

Section: Discussionmentioning

confidence: 63%

Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence

Bhar¹,

Kundu²,

Halder³

2013

Sri Lankan J Anaesthesiol

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A 15 year old female patient of ASA class I was posted for implant removal from left forearm under general anaesthesia. Intraoperative period was uneventful. In the immediate postoperative period, she became restless which subsided after administration of haloperidol and promethazine intramuscularly. On interview, she complained of intraoperative awareness. Thorough checking of the anaesthesia machine revealed that the floats in both oxygen and nitrous oxide rotameters were moving up even when both nitrous oxide cylinders were closed and one oxygen cylinder was kept open. The diaphragm of oxygen failure safety valve was found to be ruptured which allowed oxygen to flow through nitrous oxide flow meter. Preoperative checking of the anaesthesia machine could not identify these abnormalities. Thus, meticulous checking of anaesthesia machine including the oxygen failure safety valve, intraoperative monitoring of depth of anaesthesia, use of oxygen and end-tidal anesthetic gas analyzer may be helpful to prevent such an incident.

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Section: Discussionmentioning

confidence: 63%

Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence

Bhar¹,

Kundu²,

Halder³

2013

Sri Lankan J Anaesthesiol

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“…A Medline search from 1983 found that no such problems with the Midogas nitrous oxide/oxygen blender have been reported. However there have been two cases of oxygen contaminating the nitrous oxide line due to defects in the O 2 fail-safe device in anaesthetic machines 9,10 . This led to awareness in those individual patients.…”

Section: Discussionmentioning

confidence: 99%

Oxygen Contamination of the Nitrous Oxide Pipeline Supply

Lye

Patrick

1998

Anaesth Intensive Care

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Midogas® (CIG Australia) nitrous oxide/oxygen blenders are commonly used in delivery wards in Australia. In this case report we describe an incident where a small hole in the diaphragm of the oxygen failure alarm in a Midogas nitrous oxide/oxygen blender led to retrograde flow of oxygen contaminating the nitrous oxide pipeline supply to the operating theatres and the delivery ward. This caused a reduced level of nitrous oxide to the patient in theatre, but there was no adverse outcome. However, if the oxygen pipeline pressure had been lower than the nitrous oxide pipeline pressure, the contamination would have been reversed, potentially resulting in a hypoxic mixture being delivered to many patients. Suggestions are made as to a method of prevention of this problem.

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“…. The pipeline is polluted by the`wrong' gas at the point of interconnection or cross-connection of two pipelines [3]. .…”

Section: Introductionmentioning

confidence: 99%

Contamination of piped medical gas supply with water

Hay¹

2000

Eur J Anaesthesiol

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The failure of anaesthetic equipment as a result of maintenance is extremely rare. The ingress of water into the flowmeters of an anaesthetic machine from the piped medical air supply is reported and is possibly unique. The piped medical air supply was open to the atmosphere during maintenance. Water condensed in the gas pipeline and this was not noticed during subsequent testing. Water was seen leaking from the orthopaedic air tools used for surgery but was assumed to be from the autoclaving process. Later the same day, when medical air from the piped source was used as part of the gas mixture for a general anaesthetic, water was seen filling the barrel of the flowmeter air control valve. This could have had far-reaching and dangerous consequences for the patient, which were fortunately averted.

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Awareness under anaesthesia due to a defective gas‐loaded regulator

Abstract: Summary

Cited by 8 publications

References 4 publications

Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence

Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence

Oxygen Contamination of the Nitrous Oxide Pipeline Supply

Contamination of piped medical gas supply with water

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