Carbon dioxide: making the right connection

  • Matthew Winton Gibbs University of Cape Town
  • Ross Hofmeyr University of Cape Town
Keywords: anaesthesia equipment, capnography, hypercarbia, medical error

Abstract

Carbon dioxide has been used in anaesthesia since the late 1920s, principally to stimulate breathing after a period of hyperventilation in the era before routine use of capnography. The authors’ tertiary academic hospital still has the infrastructure for pipeline delivery of carbon dioxide. A case is reported of accidental administration of carbon dioxide to a patient under anaesthesia, who was found to have end-tidal carbon dioxide (EtCO2) concentrations of greater than 25 kPa immediately after induction. This was confirmed on arterial blood-gas analysis. After successful resuscitation using an alternative oxygen source, it was discovered that the high concentrations were due to misconnection of gas pipelines during the refurbishment of a theatre. This highlights safety issues concerning pipeline provision of carbon dioxide, and that it is of utmost importance to confirm correct gas connections and supply before a new theatre is commissioned. (Full text available online at www.medpharm.tandfonline.com/ojaa) South Afr J Anaesth Analg 2017; DOI: 10.1080/22201181.2017.1332292

Author Biographies

Matthew Winton Gibbs, University of Cape Town
Department of Anaesthesia & Perioperative Medicine University of Cape Town Cape Town South Africa
Ross Hofmeyr, University of Cape Town
Department of Anaesthesia & Perioperative Medicine University of Cape Town Cape Town South Africa; and Inaugural Storz-UCT African Fellow in Airway & Thoracic Anaesthesia
Published
2017-06-23
Section
Research Articles