THE OXYGEN ANALYZER - APPLICATIONS AND LIMITATIONS - AN ANALYSIS OF 2000 INCIDENT REPORTS

被引:16
作者
BARKER, L
WEBB, RK
RUNCIMAN, WB
VANDERWALT, JH
机构
[1] UNIV ADELAIDE,DEPT ANAESTHESIA & INTENS CARE,ADELAIDE,SA 5001,AUSTRALIA
[2] WOMENS & CHILDRENS HOSP,DEPT PAEDIAT ANAESTHESIA,ADELAIDE,SA,AUSTRALIA
[3] ROYAL ADELAIDE HOSP,ADELAIDE,SA 5000,AUSTRALIA
关键词
ANESTHESIA; EQUIPMENT; OXYGEN ANALYZER; OXYGEN SUPPLY FAILURE; HYPOXIC GAS MIXTURES; WRONG GAS MIXTURE; ROTAMETER PROBLEMS;
D O I
10.1177/0310057X9302100513
中图分类号
R614 [麻醉学];
学科分类号
100217 ;
摘要
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the role of the oxygen analyser; 27 (1%) were first detected by the oxygen analyser. All of these were amongst the 1256 incidents which occurred in association with general anaesthesia, of which 48% were ''human detected'' and 52% ''monitor detected'' The oxygen analyser was ranked 7th and detected 4% of these monitor detected incidents. This figure would have been much higher had the oxygen analyser been correctly used on more occasions. The oxygen analyser detected 10 ventilator-driving-gas leaks into the circuit, 6 hypoxic mixtures due to rotameter settings, 3 inappropriate nitrous oxide concentrations, 2 disconnections and 1 leak at the common gas outlet, and 2 partial and 1 total failure of ventilation. In a theoretical analysis of these 1256 incidents it was considered that the oxygen analyser, used on its own, would have detected 114 (9%), had they been allowed to evolve (3% before any potential for organ damage). In 4 incidents an oxygen analyser gave faulty readings, in 3 caused a leak and in one a total circuit obstruction; 5 incidents were not detected because the alarm had been disabled Despite the advent of piped gas supplies, failure of gas delivery or delivery of a ''wrong'' gas mixture still occurs surprisingly frequently in current anaesthetic practice; hypoxic mixtures were supplied on 16 occasions, other ''wrong'' mixtures on 23 and the oxygen supply failed on 7 occasions. Failure to use and improper use of the oxygen analyser is also surprisingly common; this is mainly due to a rule-based error encouraged by the poor design of the high alarm. It is highly recommended that a suitable, correctly sited, calibrated, tested oxygen analyser be used from before pre-oxygenation until the patient is no longer breathing gas from the anaesthetic machine or circuit.
引用
收藏
页码:570 / 574
页数:5
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