Fatal errors in nitrous oxide delivery

Summary 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 ‘claim...

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Bibliographic Details
Published in:Anaesthesia 2007-12, Vol.62 (12), p.1202-1206
Main Authors: Herff, H., Paal, P., Von Goedecke, A., Lindner, K. H., Keller, C., Wenzel, V.
Format: Article
Language:English
Subjects:
Adult
Anesthesia
Anesthesia, Inhalation - instrumentation
Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy
Anesthetics, Inhalation - administration & dosage
Anesthetics, Inhalation - poisoning
Biological and medical sciences
Equipment Failure
Fatal Outcome
Fatalities
Female
Humans
Intraoperative Complications - chemically induced
Male
Mass Media
Medical research
Medical sciences
Medication Errors
Middle Aged
Nitrous Oxide - administration & dosage
Nitrous Oxide - poisoning
Surgery
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Summary:Summary 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.
ISSN:0003-2409
1365-2044
DOI:10.1111/j.1365-2044.2007.05193.x