Nitrogen Purging of Oxygen Pipelines: An Unusual Cause of Intraoperative Hypoxia

Elizaga, Andrew M.; Frerichs, Robert L.

doi:10.1213/00000539-200007000-00045

Cited by 4 publications

(2 citation statements)

References 6 publications

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“…Based on our research, six of 70-100 anaesthesia-related deaths were probably due to inadvertent ventilation with excessive nitrous oxide. Only a few case reports describing this phenomenon were identified over 30 years [2,3], and closed claims analyses or mortality data bases, which were not targeting this phenomenon explicitly, revealed no current cases [4,5,12]. Thus, either there are no cases, or these scientific tools may have failed to detect or have underestimated the number of nitrous oxiderelated casualties.…”

Section: Discussionmentioning

confidence: 99%

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Fatal errors in nitrous oxide delivery

et al. 2007

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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.

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Section: Discussionmentioning

confidence: 99%

“…Interestingly, Medline analysis targeting severe nitrous oxide-related incidents revealed only a few case reports in the last three decades [3,4]. Further, a closed claim analysis reported only 'claims involving oxygen supply lines' predating 1990 [5], or a general decrease of respiratory-related damaging events [6].…”

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confidence: 99%