Portal de Periódicos da CAPES

Explosions in anaesthesia

2005; Elsevier BV; Volume: 94; Issue: 5 Linguagem: Inglês

10.1093/bja/aei547

1471-6771

Michael Celinski,

Disaster Response and Management

Editor—Although explosions in anaesthesia and critical care are fortunately rare these days, I would like to make readers aware of two, almost identical, serious incidents involving explosions that have happened in two hospitals. Both incidents involved the Oxylog 2000 portable ventilator and occurred in a computed tomography (CT) scanning room. In the first incident, a patient was transferred uneventfully from A&E to the CT scanner using the Oxylog ventilator. Ventilation was continued in the CT scanner with the oxygen hosing plugged into a wall mounted oxygen outlet. At the end of the procedure the oxygen hosing was in the process of being unplugged when there was a sudden explosion with flames passing a distance of about 2 m away from the oxygen outlet and lasting for less than 1 s. The explosion occurred at the bayonet end of the oxygen hosing close to the oxygen outlet almost splitting the oxygen hose (see Fig. 1). The member of staff who was in the process of unplugging the oxygen hosing from the oxygen outlet suffered extensive burns to both hands. In the second incident, a patient was transferred from ITU to the CT scanner uneventfully on an Oxylog ventilator. Again, the ventilator was connected to a wall mounted oxygen outlet during the CT scan. After about 30 min there was a sudden explosion. Neither the oxygen hosing nor ventilator were being handled or moved at the time. The flame lasted less than 1 s and originated in the same position at the bayonet end of the oxygen hose resulting in almost splitting the hose. No member of staff was injured in this incident, and in both incidents there was no harm to the patients being ventilated. In the first incident the ventilator had been serviced 1 month before. There was a visual inspection of the oxygen hosing only during this service. The oxygen hosing was just over 5 yr old. The second incident only occurred recently and information on the oxygen hosing is still unavailable. In March 2003, the Medical Devices Agency (MDA) published an alert (MDA/2003/007) highlighting the need to change oxygen hosing as per the manufacturers guidelines (usually between 2 and 5 yr), especially when used with a portable ventilator. Oxygen hoses on portable ventilators may be more at risk owing to frequent plugging and unplugging, and frequent flexing of the hosing, resulting in more stress on the hosing. However, oxygen hoses do not have a ‘use by date’ stamped on them and therefore only the manufacturers know how old the hoses are. The MDA are in the process of investigating these two incidents and their recommendations are awaited. Departments should regularly check all their oxygen hosing, especially those on portable ventilators where the oxygen hosing may not be covered by the routine ventilator service, to ensure that the MDA/2003/007 alert is being followed.