We wish to report a critical anaesthetic incident which illustrates a shortcoming of an integrated monitoring system. A fit 22-year-old man was scheduled for an open meniscectomy. He was preoxygenated with 100% oxygen for two minutes and anaesthesia was induced with propofol and atracurium intravenously. The inspired gas concentrations were adjusted and thought to be isoflurane 1 % in nitrous oxide and oxygen (F I o 2 0.33), delivered via a Mapleson A breathing system. The patient was ventilated by mask for approximately one minute and intubated without difficulty, but he immediately became cyanosed. Extubation was performed and when the F I o 2 was adjusted to 1.0, it was noticed that the previous mixture had contained approximately 10% oxygen. The patient FIGURE I.-Screen display of Datex Cardiocap integrated monitor.
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