title: Inadvertent positive end-expiratory pressure caused by a malfunctioning ventilator relief valve.
abstract: 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.
authors.affiliation: *Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland; and †Anesthesiology Service, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland.
authors.forename: Denis L
authors.initials: DL
authors.lastname: Bourke
authors.forename: David
authors.initials: D
authors.lastname: Tolentino
mesh_terms: D000368:Aged; D000768:Anesthesia, General / Q000295:instrumentation*; D004868:Equipment Failure; D006801:Humans; D008297:Male; D011175:Positive-Pressure Respiration; D012121:Respiration, Artificial / Q000295:instrumentation*