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Anesthesia and analgesia · Aug 2003
Case ReportsInadvertent positive end-expiratory pressure caused by a malfunctioning ventilator relief valve.
- Denis L Bourke and David Tolentino.
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA. BourkedenisL@aol.com
- Anesth. Analg. 2003 Aug 1;97(2):492-3, table of contents.
ImplicationsDuring anesthesia, a nurse draped several gas hoses over the ventilator relief valve on the back of the anesthesia machine, causing a malfunction. Unintended positive end-expiratory pressure was administered to the patient. Causes of this mishap, anesthesia machine design, and nonanesthesiologist familiarity with anesthesia machine components and their function, are discussed.
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