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

Abstract

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.

Curious case of a spurious medical gas cylinder

“…Pauling and Ball reviewed case reports pertaining to the delivery of anoxic gas mixtures to the patients, both prior to and after the obligatory safety checklist. [ 5 ] The safety features are prone to disregard which may arise out of unawareness, disinterest or accident. This can occur at any point in the process, manufacturer, supplier or end user.…”

Severe and acute hypercapnia, subsequent to the mistaken connection of a carbon dioxide cylinder on the nitrous oxide manifold: a report of three simultaneous cases

“…A multitude of gas supply errors can occur throughout the entire process of gas supply, spanning from the cylinders to the anesthesia machine 4,5,6 . Cylinder-related errors encompass mislabeling, inadequate gas supply and the inadvertent introduction of incorrect gases.…”

“…Considering the evolution of safety in the administration of medical gases 2,3 , it would be assumed nowadays that the patient does indeed receive the correct gas requested by the anesthesiologist on the anesthesia machine. Many anesthesiologists take this for granted, but this might not always be the case 4,5,6 . The anesthesia machine verification procedure, as part of the checklist, does not allow adequate control for all gas delivery.…”

Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya

“…Failure or absence of this alarm could lead to mortality. 28 There could be improper maintenance practices or inadequate presence of maintenance resources and personnel. A definitive conclusion could not be drawn because the study was designed as a cross-sectional audit.…”