Severe Carbon Monoxide Poisoning during Desflurane Anesthesia

Berry, Peter D.; Sessler, Daniel I.; Larson, Merlín D.

doi:10.1097/00000542-199902000-00036

Cited by 55 publications

(16 citation statements)

References 16 publications

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“…reported a case of carbon monoxide poisoning during desflurane anaesthesia. [3] Kanno et al . have reported combustive destruction of the anaesthetic circuit expiratory valve[4] and explosions within the anaesthesia machine were reported by Castro et al .…”

Section: Discussionmentioning

confidence: 99%

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Cardiac arrest following ventilator fire: A rare cause

2012

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Operating room fires are rare events, but when occur they result in serious and sometimes fatal consequences. Anaesthesia ventilator fire leading to cardiac arrest is a rare incident and has not been reported. We report a near catastrophic ventilator fire leading to cardiac arrest in a patient undergoing subtotal thyroidectomy. In the present case sparks due to friction or electrical short circuit within the ventilator might have acted as source of ignition leading to fire and explosion in the oxygen rich environment. The patient was successfully resuscitated and revived with uneventful recovery and no adverse sequelae. The cardiac arrest was possibly due to severe hypoxia resulting from inhalation of smoke containing high concentrations of carbon monoxide and other noxious gases.

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Section: Discussionmentioning

confidence: 99%

“…[12] Cardiac arrest associated with ventilator fire has not been reported in the published English literature. [3] We report a near-fatal incident of cardiac arrest following ventilator mishap and successful revival of a patient who underwent subtotal thyroidectomy.…”

Section: Introductionmentioning

confidence: 99%

Cardiac arrest following ventilator fire: A rare cause

2012

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“…However, there are reports of severe CO intoxications [2,3] recently published by Berry et al [14] with desflurane as anesthetic agent. The highest risk develops when fresh gas flow is maintained in a anesthesia system for a few days.…”

Section: Discussionmentioning

confidence: 99%

Carbon monoxide production from five volatile anesthetics in dry sodalime in a patient model: halothane and sevoflurane do produce carbon monoxide; temperature is a poor predictor of carbon monoxide production

2005

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“…15 Measures to decrease this potential hazard include using absorbent that has the standard complement of water, or addition of liquid R4 water to the top of the absorbent. 15 Fresh gas should be turned off at the end of each case to prevent drying out of the absorbent and consideration should be given to replacing the absorbent more frequently, especially if the machine has been left unused for some time, such as over a weekend. 16 A more simple solution would be to use CO 2 absorbents that do not contain strong base.…”

Section: Anesthetic Gases and Nitrogenmentioning

confidence: 99%

Hazards of anesthesia gas delivery systems

Eisenkraft

2004

Can J Anesth/J Can Anesth

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HE anesthesia delivery system comprises the anesthesia machine, vaporizers, ventilator, and waste gas scavenging system. Failure of the delivery system is a rare cause of anesthesia-related injury to, or death of, a patient. More commonly the delivery system is misused, the anesthesia caregiver makes an error, or the delivery system fails while the user is unaware that a failure has occurred. This lecture will review failures and complications of delivery systems from the viewpoint of how they may be detected and thereby harm to the patient prevented. 3 A mishap was labelled a CI when it was clearly an occurrence that could have led, if not discovered or corrected in time, or did lead to an undesirable outcome, ranging from increased length of hospital stay to death or permanent disability. Other CI study inclusion criteria were: that each incident involved an error by a member of the anesthesia team or a failure of the anesthesiologist's equipment to function properly; it occurred during patient care; it could be clearly described; and the incident was clearly preventable. 3Of the 1,089 CIs, 70 represented errors or failures that had contributed in some way to a "substantive negative outcome" (SNO) defined as mortality, cardiac arrest, cancelled operative procedure, or extended stay in the postanesthesia care unit, intensive care unit or in the hospital. While some 30% of all CIs were related to equipment failures, including breathing circuit disconnections, misconnections, ventilator malfunctions, and gas flow control errors, only three (4.3%) of SNO incidents involved equipment failure, suggesting that human error was the dominant problem in CIs. Although equipment failures rarely cause death, CIs related to equipment are common and have prompted improvements in equipment design, construction and in monitoring.In 1993, the Australian Anaesthesia Patient Safety Foundation published results of the Australian incident monitoring study (AIMS) that had collected 2,000 CIs. 4 Of these, 177 (9%) were due to equipment failure in general and 107 (60%) involved the anesthesia delivery system.5 Failures included problems due to unidirectional valves, ventilator malfunctions, gas or electrical supply, circuit integrity, vaporizers, absorbers and pressure regulators. Concerning the problems with ventilation, it was recommended that critical areas be doubly or triply monitored and that monitoring equipment be self-activating. 6 The role of equipment failures leading to malpractice litigation in the United States has been studied by the American Society of Anesthesiologists Closed Claims Project. A 1997 analysis of 3,791 claims, 7 of which 76% occurred during the period 1980 to 1990, found that gas delivery equipment problems accounted for 72/3,791 (2%).7 Of these 72, 39% were related to the breathing circuit, 17% to ventilators, 21% to vaporizers, 11% to gas tanks or lines and 7% to the anesthesia machine. Death or brain damage occurred in 76% of these 72 cases. Initiating events were circuit misconnects, disconnects and g...

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Severe Carbon Monoxide Poisoning during Desflurane Anesthesia

Cited by 55 publications

References 16 publications

Cardiac arrest following ventilator fire: A rare cause

Cardiac arrest following ventilator fire: A rare cause

Carbon monoxide production from five volatile anesthetics in dry sodalime in a patient model: halothane and sevoflurane do produce carbon monoxide; temperature is a poor predictor of carbon monoxide production

Hazards of anesthesia gas delivery systems

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