Inadvertent positive end-expiratory pressure caused by a malfunctioning ventilator relief valve.
During anesthesia, a nurse draped several gas hoses over the ventilator relief valve on the back of the anesthesia machine, causing a malfunction. Unintended positive end-expiratory pressure was administered to the patient. Causes of this mishap, anesthesia machine design, and nonanesthesiologist familiarity with anesthesia machine components and their function, are discussed.
Bourke
Denis L
DL
*Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland; and †Anesthesiology Service, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland.
Tolentino
David
D
D000368:Aged; D000768:Anesthesia, General / Q000295:instrumentation*; D004868:Equipment Failure; D006801:Humans; D008297:Male; D011175:Positive-Pressure Respiration; D012121:Respiration, Artificial / Q000295:instrumentation*