The inadvertent crossover between O2 and N2O pipelines has become extremely rare in practice. We describe a case where it was possible to ventilate with 100% N2O instead of the intended 100% O2 on a modern anesthesia delivery system (Dräger Apollo; Drägerwerk AG & Co KgaA, Lübeck, Germany). This was the result of the incorrect assembly of diameter index safety system (DISS) components during preventative maintenance that defeated the DISS failsafe system. To make incorrect assembly easier to avoid, DISS component labeling could be more prominent and color-coded, or the internal construction of the gas manifold could incorporate DISS.
Download full-text PDF |
Source |
|---|---|
| http://dx.doi.org/10.1213/XAA.0000000000001337 | DOI Listing |
Publication Analysis
Top Keywords
modern anesthesia
8
incorrect assembly
8
100% nitrous
4
nitrous oxide
4
oxide oxygen
4
oxygen happen
4
happen modern
4
anesthesia machine?
4
machine? inadvertent
4
inadvertent crossover
4
Similar Publications
Want AI Summaries of new PubMed Abstracts delivered to your In-box?
Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!