Fatal errors in nitrous oxide delivery.
Nitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported 'claims involving oxygen supply lines' predating 1990. The aim of this study was to assess the frequency of nitrous oxide-related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide-related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide-related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation-related deaths. Searching non-scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.
Herff
H
H
Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria. holger.herff@i-med.ac.at
Paal
P
P
von Goedecke
A
A
Lindner
K H
KH
Keller
C
C
Wenzel
V
V
D000328:Adult; D000769:Anesthesia, Inhalation / Q000295:instrumentation; D018685:Anesthetics, Inhalation / Q000008:administration & dosage / Q000506:poisoning*; D004868:Equipment Failure; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000139:chemically induced*; D008297:Male; D008402:Mass Media; D008508:Medication Errors; D008875:Middle Aged; D009609:Nitrous Oxide / Q000008:administration & dosage / Q000506:poisoning*
D018685:Anesthetics, Inhalation; D009609:Nitrous Oxide