Herrera A, Bueno F
Servicio de Anestesiología y Reanimación, Hospital General, Hospital Universitario Virgen del Rocío, Sevilla.
Rev Esp Anestesiol Reanim. 1995 Mar;42(3):96-9.
An incident involving central oxygen supply failure affecting 4 anesthetized patients in the operating theatre was analyzed by way of interviews with the anesthesiologists and a review of graphic records of anesthesia. The 4 ventilators involved had been checked by each anesthesiologist according to his own method. The oxygen supply failure alarm warned of the supply cutoff in 2 cases and the oxygen analyzer detected the other 2 within approximately 1 minute. After the failure, 2 patients were ventilated with ambient air through the ventilator, 1 was given medicinal air with the resuscitator. None suffered damage or recalled having awakened as a result of the incident. The cause of the failure in oxygen supply has not been determined but its duration has been estimated to be between 4 and 7 minutes. Our investigation shows that: 1) the operating rooms are not equipped with an alarm that warns of a drop in pressure within the tubes that supply central oxygen and in 2 cases the alarm warning of a cutoff in oxygen supply to the respirator did not sound correctly; 2) the ventilator equipment check did not follow a standard method and did not cover the possibility of oxygen supply failure, and 3) no alternative oxygen supply is available inside the operating theatre.(ABSTRACT TRUNCATED AT 250 WORDS)
通过与麻醉师面谈并查阅麻醉图表记录，对一起影响手术室4名麻醉患者的中央供氧故障事件进行了分析。所涉及的4台呼吸机由每位麻醉师按各自方法进行了检查。氧气供应故障警报在2例中警示了供应中断，另外2例中氧气分析仪在大约1分钟内检测到了故障。故障发生后，2例患者通过呼吸机用环境空气进行通气，1例使用复苏器给予医用空气。无人因该事件受到损害或回忆起曾苏醒。氧气供应故障原因尚未确定，但估计持续时间在4至7分钟之间。我们的调查显示：1）手术室未配备警示中央供氧管道内压力下降的警报器，且在2例中呼吸机氧气供应中断警报未正常响起；2）呼吸机设备检查未遵循标准方法，未涵盖氧气供应故障的可能性；3）手术室内没有备用氧气供应。（摘要截取自250字）
