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Cardiac arrest caused by an incorrectly filled oxygen cylinder: a case report
1Department of Anesthesiology, Chang Gung Memorial Hospital, Kaohsiuang Hsien, Taiwan.
British Journal of Anaesthesia
|June 1, 1990
Abstract:
One hundred percent carbon dioxide was administered accidentally to a child aged 21 months during anaesthesia; this was caused by unauthorized filling of an oxygen cylinder with carbon dioxide. Cardiac arrest ensued, but was detected and treated promptly and no neurological deficit was detectable following recovery. The case demonstrates a typical preventable anaesthetic mishap and emphasizes the importance of monitoring oxygen supply and delivery.