Pauling M, Ball C M
Provisional Fellow in Anaesthesia, Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria.
Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Victoria.
Anaesth Intensive Care. 2017 Mar;45(7):21-28. doi: 10.1177/0310057X170450S104.
In 1983 a patient at The Alfred Hospital, Melbourne died during general anaesthesia for emergency surgery, in the weeks following maintenance to the operating theatre gas supply. In the ensuing investigation, it was revealed that he had been given 100% nitrous oxide throughout the anaesthetic due to the inadvertent crossing of the nitrous oxide and oxygen pipelines during the repair work. In this article we review the published literature on the delivery of hypoxic and anoxic gas mixtures, and the associated morbidity and mortality. We explore the developments that took place in the delivery of anaesthetic gases, and the unforeseen dangers associated with these advances. We consider the risks to patient safety when technological advances outpaced the implementation of essential safety standards. We investigate the events that pushed the development of safer standards of anaesthetic practice and patient monitoring, which have contributed to modern day theatre practice. Finally, we consider the risks that still exist in the hospital environment, and the need for on-going vigilance.
1983年，墨尔本阿尔弗雷德医院的一名患者在急诊手术全身麻醉期间死亡，此前数周手术室的气体供应进行了维护。在随后的调查中发现，由于维修工作中一氧化二氮和氧气管道意外交叉，他在整个麻醉过程中吸入的都是100%的一氧化二氮。在本文中，我们回顾了关于低氧和缺氧气体混合物输送以及相关发病率和死亡率的已发表文献。我们探讨了麻醉气体输送方面的发展，以及这些进步带来的意外危险。我们考虑了技术进步超过基本安全标准实施时对患者安全的风险。我们调查了推动更安全麻醉实践和患者监测标准发展的事件，这些事件促成了现代手术室实践。最后，我们考虑医院环境中仍然存在的风险，以及持续保持警惕的必要性。
