Why the study?
Inadvertent crossover between O2 and N2O pipelines has become extremely rare, but understanding how it could occur on a modern anesthesia delivery system remains important.
Incorrect assembly of DISS components during maintenance can defeat failsafe systems on modern anesthesia machines, highlighting the need for better labeling or internal construction.
The inadvertent crossover between O2 and N2O pipelines has become extremely rare in practice. We describe a case where it was possible to ventilate with 100% N2O instead of the intended 100% O2 on a modern anesthesia delivery system (Dräger Apollo; Drägerwerk AG & Co KgaA, Lübeck, Germany). This was the result of the incorrect assembly of diameter index safety system (DISS) components during preventative maintenance that defeated the DISS failsafe system. To make incorrect assembly easier to avoid, DISS component labeling could be more prominent and color-coded, or the internal construction of the gas manifold could incorporate DISS.
No takes yet. Share an insight, caveat, or question.
Joo et al. (2020) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: