Fatal respiratory thermal injury following accidental administration of carbon dioxide using the circle system for a cesarean delivery.
A 37-year-old parturient underwent emergency cesarean delivery because of severe preeclampsia. After induction of general anesthesia, the oxygen saturation decreased. Volatile anesthetics were discontinued and examination of the anesthetic circuit and machine revealed a soda lime canister that was extremely hot. The patient was detached from the anesthetic machine and hand-ventilated with an external oxygen cylinder. The surgery was cancelled and the patient was extubated. Analysis of the cylinder connected to the anesthesia machine displayed 100% carbon dioxide. The patient developed progressive respiratory failure. Bronchoscopic examination revealed burn scars from the carina to the main bronchi. The patient died within four months of the incident.
Aghdashi
M M
MM
Department of Anesthesia, Mothahari Hospital, Urmia Medical Science University, Urmia Iran. Aghdashi@umsu.ac.ir
Abbasivash
R
R
Hassani
E
E
Pirnejad
H
H
D000328:Adult; D000768:Anesthesia, General / Q000009:adverse effects* / Q000295:instrumentation*; D000773:Anesthesia, Obstetrical / Q000009:adverse effects* / Q000295:instrumentation*; D001784:Blood Gas Analysis; D002245:Carbon Dioxide / Q000009:adverse effects*; D002585:Cesarean Section; D004868:Equipment Failure; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D019300:Medical Errors; D010100:Oxygen / Q000097:blood; D011225:Pre-Eclampsia / Q000503:physiopathology; D011247:Pregnancy; D012131:Respiratory Insufficiency / Q000209:etiology; D012137:Respiratory System / Q000293:injuries*
D002245:Carbon Dioxide; D010100:Oxygen