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Gas Mix-Up Causes Newborn Death

Gas Mix-Up Causes Newborn Death
Author Information (click to view)

Skeptical Scalpel

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 300,000 page views, and he has over 3,700 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 300,000 page views, and he has over 3,700 followers on Twitter.

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In mid-July, a baby born by cesarean section died about one hour later due to the administration of nitrous oxide instead of oxygen in the hospital’s neonatal resuscitation area.

Nitrous oxide, an anesthetic, was apparently mistakenly connected to an oxygen outlet in the baby’s room at the Bankstown-Lidcombe Hospital in Sydney, Australia. Another baby treated in the same location in June of this year suffered severe brain damage presumably due to the the unrecognized nitrous oxide error.

A pediatrician figured out what happened after the death of the baby in July.

One report says that the company that installed and certified the gas lines was responsible for the error, and another says that the company, the hospital, and an anesthetist supposedly signed off on the installation. An investigation is still in progress.

The faulty installation took place in January 2015 but the room in which the two babies were resuscitated was infrequently used.

Although the baby died on July 13, the parents were not told the cause until 10 days later.

Many years ago, hospitals and regulatory agencies acted to prevent gas mix-ups by standardizing couplings. For example, an oxygen hose coupling will not fit into a nitrous oxide outlet because the configurations of the connections for the two gases are different.

As the events in Sydney illustrate, a mistaken hook up between a storage container and a pipe leading to the wall outlet is still possible.

Several questions come to mind.

  1. Why didn’t any of the caregivers notice the subtle but distinctly sweet odor of nitrous oxide?
  1. Who signed off on the gas line installation, and what were the criteria they used to determine it was correct?
  1. What did the staff do as the baby’s oxygenation fell? In 2016, most patients receiving supplemental oxygen, particularly those being resuscitated, are monitored by pulse oximetry, a noninvasive and accurate device if used correctly. As the baby’s lungs filled with nitrous oxide, the oxygen saturation in the blood would have gradually started falling to alarmingly low levels.
  1. Surely the case of the baby who suffered brain damage in June must have been investigated. What were the findings?

I am so sorry for the families of these unfortunate babies and hope the inquiry into the July baby’s death addresses these issues.

As if the hospital did not have enough problems, two more unusual occurrences have come to light. In January 2014, a third child suffered “long-term health problems” when a tank ran out of oxygen during a resuscitation, and on July 25th of this year, an Iraqi refugee apparently committed suicide in the hospital’s mental health unit.

 

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 300,000 page views, and he has over 3,700 followers on Twitter.

1 Comment

  1. Although Wikipedia says there is a sweet odor, standard texts say that nitrous oxide is odorless and that is certainly my belief after 36 years of anesthesia practice (although I have not used it for more than 10 years.)
    D. McKnight
    Professor of Anesthesia
    University of Torornto

    Reply

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