Carbon dioxide: making the right connection

Abstract

Carbon dioxide has been used in anaesthesia since the late 1920s, principally to stimulate breathing after a period of hyperventilation in the era before routine use of capnography. The authors’ tertiary academic hospital still has the infrastructure for pipeline delivery of carbon dioxide. A case is reported of accidental administration of carbon dioxide to a patient under anaesthesia, who was found to have end-tidal carbon dioxide (EtCO₂) concentrations of greater than 25 kPa immediately after induction. This was confirmed on arterial blood-gas analysis. After successful resuscitation using an alternative oxygen source, it was discovered that the high concentrations were due to misconnection of gas pipelines during the refurbishment of a theatre. This highlights safety issues concerning pipeline provision of carbon dioxide, and that it is of utmost importance to confirm correct gas connections and supply before a new theatre is commissioned.

Keywords: anaesthesia equipment, capnography, hypercarbia, medical error