Document Detail

Fatal respiratory thermal injury following accidental administration of carbon dioxide using the circle system for a cesarean delivery.
MedLine Citation:
PMID:  19734035     Owner:  NLM     Status:  MEDLINE    
A 37-year-old parturient underwent emergency cesarean delivery because of severe preeclampsia. After induction of general anesthesia, the oxygen saturation decreased. Volatile anesthetics were discontinued and examination of the anesthetic circuit and machine revealed a soda lime canister that was extremely hot. The patient was detached from the anesthetic machine and hand-ventilated with an external oxygen cylinder. The surgery was cancelled and the patient was extubated. Analysis of the cylinder connected to the anesthesia machine displayed 100% carbon dioxide. The patient developed progressive respiratory failure. Bronchoscopic examination revealed burn scars from the carina to the main bronchi. The patient died within four months of the incident.
M M Aghdashi; R Abbasivash; E Hassani; H Pirnejad
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Publication Detail:
Type:  Case Reports; Journal Article     Date:  2009-09-05
Journal Detail:
Title:  International journal of obstetric anesthesia     Volume:  18     ISSN:  1532-3374     ISO Abbreviation:  Int J Obstet Anesth     Publication Date:  2009 Oct 
Date Detail:
Created Date:  2009-09-28     Completed Date:  2009-12-07     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9200430     Medline TA:  Int J Obstet Anesth     Country:  Netherlands    
Other Details:
Languages:  eng     Pagination:  400-2     Citation Subset:  IM    
Department of Anesthesia, Mothahari Hospital, Urmia Medical Science University, Urmia Iran.
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MeSH Terms
Anesthesia, General / adverse effects*,  instrumentation*
Anesthesia, Obstetrical / adverse effects*,  instrumentation*
Blood Gas Analysis
Carbon Dioxide / adverse effects*
Cesarean Section*
Equipment Failure
Fatal Outcome
Medical Errors
Oxygen / blood
Pre-Eclampsia / physiopathology
Respiratory Insufficiency / etiology
Respiratory System / injuries*
Reg. No./Substance:
124-38-9/Carbon Dioxide; 7782-44-7/Oxygen

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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