Chemotherapy Research Today is a free monthly online journal that collates and summarizes the latest research about Chemotherapy, including details on cancer treatment, side effects, drugs.

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V

Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria. holger.herff@i-med.ac.at

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.

Published 9 November 2007 in Anaesthesia, 62(12): 1202-6.
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