Hazard in administering nitrous oxide analgesia: report of case

Upton, L. George; Robert, Richard C.

doi:10.14219/jada.archive.1977.0313

Cited by 3 publications

(3 citation statements)

References 1 publication

Supporting

Mentioning

Contrasting

Order By: Relevance

“…It was possible to connect these gas leads upside down, enabling the nitrous oxide connector to fit the oxygen cylinder yoke 19 (Figure 3 and 4). Failure of this system resulted in administration of 100% nitrous oxide in a dental surgery 20 . A missing pin led to the ability to fit a nitrous oxide cylinder to the oxygen yoke connector, and there has been a case report of a nitrous oxide cylinder whose valve had the pin index configuration for oxygen 21,22 .…”

Section: Cylindersmentioning

confidence: 99%

Delivery of Anoxic Gas Mixtures in Anaesthesia: Case Report and Review of the Struggle towards Safer Standards of Care

Pauling

Ball

2017

Anaesth Intensive Care

View full text Add to dashboard Cite

In 1983 a patient at The Alfred Hospital, Melbourne died during general anaesthesia for emergency surgery, in the weeks following maintenance to the operating theatre gas supply. In the ensuing investigation, it was revealed that he had been given 100% nitrous oxide throughout the anaesthetic due to the inadvertent crossing of the nitrous oxide and oxygen pipelines during the repair work. In this article we review the published literature on the delivery of hypoxic and anoxic gas mixtures, and the associated morbidity and mortality. We explore the developments that took place in the delivery of anaesthetic gases, and the unforeseen dangers associated with these advances. We consider the risks to patient safety when technological advances outpaced the implementation of essential safety standards. We investigate the events that pushed the development of safer standards of anaesthetic practice and patient monitoring, which have contributed to modern day theatre practice. Finally, we consider the risks that still exist in the hospital environment, and the need for ongoing vigilance.

show abstract

Section: Cylindersmentioning

confidence: 99%

Delivery of Anoxic Gas Mixtures in Anaesthesia: Case Report and Review of the Struggle towards Safer Standards of Care

Pauling

Ball

2017

Anaesth Intensive Care

View full text Add to dashboard Cite

show abstract

“…Unfortunately, deaths still continue to occur from failure to simultaneously deliver adequate amounts of O2 due to equipment malfunction, unrecognised cross-connections of the N 20 and O2 lines, erroneous gas cylinder labelling, or other human error (Editorial 1974;Lebourdais 1974;Sawhney & Yoon 1983;Upton & Roberts 1977). However, since in modem anaesthetic practice O2 is now always administered in concentrations greater than room air, the patient breathes more than an adequate amount of O2 during a N20 anaesthetic.…”

Section: Hypoxiamentioning

confidence: 99%

Adverse Effects of Nitrous Oxide

Brodsky

Cohen

1986

Medical Toxicology

View full text Add to dashboard Cite

Although once considered completely devoid of complications, it is now recognised that the misuse or inappropriate use of nitrous oxide (N2O) often results in adverse side effects. Hypoxia, particularly the entity 'diffusion hypoxia', can occur with the administration of inadequate amounts of oxygen during or immediately after a N2O anaesthetic. N2O will diffuse into air-containing cavities within the body faster than nitrogen diffuses out. This results in a temporary increase in either the pressure and/or volume of the cavity depending upon the distensibility of its walls. The magnitude of the effect is proportional to the blood supply of the cavity, the concentration of N2O inhaled and the length of time the patient is exposed to N2O. Significant morbidity or even death can result from this phenomenon. A property unique to N2O is its ability to oxidise and inactivate the vitamin B12 components of certain enzymes in both animals and man. One such enzyme, methionine synthetase is essential for normal DNA production. Animal and human studies have demonstrated that the haematological, immune, neurological and reproductive systems are each affected. These adverse effects of N2O can occur after both acute (surgical) or long term (occupational) exposure to the gas. Because of its effects on the pressure and volume characteristics of air-containing spaces, N2O should not be used for patients with bowel obstruction, pneumothorax, middle ear and sinus disease, and following cerebral air-contrast studies. Many anaesthesiologists feel that use of N2O should be restricted during the first two trimesters of pregnancy because of its effects on DNA production and the experimental and epidemiological evidence that N2O causes undesirable reproductive outcomes. Since N2O affects white blood cell production and function, it has been recommended that N2O not be administered to immunosuppressed patients or to patients requiring multiple general anaesthetics. Many anaesthesiologists believe that the potential dangers of N2O are so great that it should no longer be used at all for routine clinical anaesthesia. However, the continued use of N2O remains a controversial topic since, at present, a suitable substitute gas is not available.

show abstract

“…Several accidents resulting from crossed nitrous oxide and oxygen pipelines have been reported recently, with the deaths of an infant and of an eight-year-old boy in India 4 and at least two deaths reported in Italy in 2007. 5 Yet this is not a problem that has developed in recent JHD 2016:1(2):2-5 EDITORIAL times: gas pipeline errors within hospitals are an ongoing problem and have been the subject of many publications over several decades, 6,7 many of which highlight the causes and detail methods for prevention of similar accidents. Between April 2004 and October 2006, six cases of nitrous oxide-related deaths were identified in Germany, Austria, and Switzerland.…”

Section: Introductionmentioning

confidence: 99%

Out of sight killers—the ongoing problem with hospital gas lines

Cornwall¹,

Robinson²

2016

JHD

View full text Add to dashboard Cite

The recent death of one neonate and injury to another due to resuscitation with nitrous oxide and not oxygen highlights the continuing risk associated with the delivery of piped nitrous oxide into hospitals. The cause of this incident was not unique, with many identical deaths and injuries occurring frequently around the world over several decades. While standards and design focus are often directed at the equipment used by clinicians, attention also needs to be directed at developing safety mechanisms throughout an entire gas delivery process to prevent ongoing tragedies associated with gas-delivery errors.

show abstract

Hazard in administering nitrous oxide analgesia: report of case

Cited by 3 publications

References 1 publication

Delivery of Anoxic Gas Mixtures in Anaesthesia: Case Report and Review of the Struggle towards Safer Standards of Care

Delivery of Anoxic Gas Mixtures in Anaesthesia: Case Report and Review of the Struggle towards Safer Standards of Care

Adverse Effects of Nitrous Oxide

Out of sight killers—the ongoing problem with hospital gas lines

Contact Info

Product

Resources

About