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Inadvertent positive end-expiratory pressure caused by a malfunctioning ventilator relief valve
Denis L Bourke1, David Tolentino
1*Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland; and †Anesthesiology Service, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland.
Anesthesia and Analgesia
|July 23, 2003
Abstract
Implications:
During 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.