Inadvertent positive end-expiratory pressure caused by a malfunctioning ventilator relief valve.

Bourke, Denis L; Tolentino, David · Anesth Analg · 2003

case_report · Level V

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Abstract

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.

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