Tension pneumothorax and cardiac arrest from an improvised oxygen delivery system

Patient Injuries from Anesthesia Gas Delivery Equipment

“…In many of these cases, nurses or technicians contributed to the problems, often associated with lack of familiarity and improvised systems. Wax et al 18 reported use of an improvised system for delivering Anesthesia Gas Delivery Claims supplemental oxygen to a spontaneously breathing, intubated patient for transport to the postanesthesia care unit, resulting in barotrauma. 18 In another report, during resuscitation of a patient with postpartum hemorrhage, a trainee, unnoticed, connected the oxygen delivery (at 10 l/min) tubing directly into the tracheal tube connector causing pulmonary barotrauma with a fatal outcome.…”

“…Wax et al 18 reported use of an improvised system for delivering Anesthesia Gas Delivery Claims supplemental oxygen to a spontaneously breathing, intubated patient for transport to the postanesthesia care unit, resulting in barotrauma. 18 In another report, during resuscitation of a patient with postpartum hemorrhage, a trainee, unnoticed, connected the oxygen delivery (at 10 l/min) tubing directly into the tracheal tube connector causing pulmonary barotrauma with a fatal outcome. 19 Use of standard transportation oxygen supply line equipment, total avoidance of improvised delivery devices, and improved education for personnel outside the operating room who participate in oxygen delivery equipment set-up may help to prevent such errors.…”