Fatal errors in nitrous oxide delivery

Abstract

SummaryNitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported ‘claims involving oxygen supply lines’ predating 1990. The aim of this study was to assess the frequency of nitrous oxide‐related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide‐related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide‐related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation‐related deaths. Searching non‐scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.

Lachgasbedingte Todesfälle

“…Aufgrund fehlender fachwissenschaftlicher Publikationen wurden in einem früheren Artikel Zeitungsarchive zur Detektion tödlicher lachgasbedingter Komplikationen ausgewertet [9]. In ähnlicher Weise diente nun das Internet als Datenquelle.…”

“…Während die lachgasbedingten Todesfäl-le in der Laienpresse teils heftig diskutiert wurden ( [4]), erschienen sie offensichtlich in keinem der entsprechenden medizinischen Fachjournale [9]. Ein Fehlen dieser Komplikationen in den bestehenden Fehlermeldesystemen kann aber auch nicht sonderlich überraschen, wenn man die Grundlage dieser "Critical-incident"-Reportsysteme" (CIRS) bedenkt.…”

Anaesthesia machine: Checklist, hazards, scavenging

“…[78] Misconnection of O 2 pipeline hose to N 2 O cylinder in the manifold room by technical personnel has resulted in hypoxic gas delivery. [910] Insertion of the Equanox (50% each of O 2 and N 2 O) probe accidentally into the N 2 O wall outlet resulted in 100% N 2 O delivery. [11] These problems were compounded by either lack of oxygen analyser or failure to recognise the hypoxia early and changing over to an alternate plan by the concerned anaesthesiologist.…”

Medicinal Gases and Volatile Anesthetics

“…Gilmour et al [12] reported a case of oxygen supply contamination with trichloroeth ane, originated from the fluid used to clean the hose that connected the [13][14][15][16]. Gilmour et al [12] reported a case of oxygen supply contamination with trichloroeth ane, originated from the fluid used to clean the hose that connected the [13][14][15][16].…”