Fatal errors in nitrous oxide delivery
Summary Nitrous 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 ‘claim...
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Published in | Anaesthesia Vol. 62; no. 12; pp. 1202 - 1206 |
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Main Authors | , , , , , |
Format | Journal Article |
Language | English |
Published |
Oxford, UK
Blackwell Publishing Ltd
01.12.2007
Blackwell |
Subjects | |
Online Access | Get full text |
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Summary: | Summary
Nitrous 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. |
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Bibliography: | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 |
ISSN: | 0003-2409 1365-2044 |
DOI: | 10.1111/j.1365-2044.2007.05193.x |