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Anesth Analg. 2004 Oct;99(4):1164-5, table of contents.

Fatal connection: death caused by direct connection of oxygen tubing into a tracheal tube connector.

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Department of Anesthesiology, Indira Gandhi Medical College, Shimla, India.


During cardiopulmonary resuscitation, oxygen extension tubing was mistakenly connected into the tracheal tube connector. As a result, the patient recovering from hypovolemic cardiac arrest died because of pulmonary barotrauma. Similar cases have been reported. We suggest that a worldwide equipment performance standard be developed to prevent future occurrences and describe an example of connectors that would prevent such misconnections.

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