title: An analysis of the factors leading to crossed gas lines causing profound hypercarbia during general anesthesia.
abstract: With increasing use of laparoscopic techniques to facilitate surgical procedures in closed cavities, our institution has installed piped-in carbon dioxide (CO2) in most of our operating rooms. This case report describes an occurrence of a nitrous oxide hose being connected to a CO2 outlet, resulting in profound hypercarbia. The factors, human and mechanical, leading to this error are discussed, as well as the process of diagnosis and the subsequent treatment.
authors.affiliation: Department of Anesthesia, University of Iowa College of Medicine, Iowa City 52242.
authors.forename: F L
authors.initials: FL
authors.lastname: Scamman
mesh_terms: D000062:Accidents, Occupational / Q000517:prevention & control; D000328:Adult; D000768:Anesthesia, General; D002245:Carbon Dioxide / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000209:etiology*; D009609:Nitrous Oxide / Q000008:administration & dosage*
chemical_list: D002245:Carbon Dioxide; D009609:Nitrous Oxide