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Lachgasbedingte Todesfälle

Komplikationen durch Verwechslungen in der Lachgaszufuhr

Fatalities due to nitrous oxide

Complications from mistakes in nitrous oxide supply

  • Fehler und Gefahren
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Zusammenfassung

Trotz gesetzlicher Vorschriften in der europäischen Norm EN 740 zur Verwendung von Messgeräten der inspiratorischen Sauerstofffraktion (FIO2-Meter) treten Todesfälle durch fälschliche Beatmung mit reinem Lachgas häufiger auf als erwartet, insbesondere nach Bau- oder Reparaturmaßnahmen an den Gasleitungen. Sofern Lachgas weiter in einer Klinik verwendet werden soll, sollten daher alle technischen und logistischen Schutzmaßnahmen zur Prävention von Zwischenfällen ergriffen werden. Dazu gehört neben einer Messung der inspiratorischen Sauerstoffkonzentration eine automatische Lachgasbeschränkung. Hinzu kommt die genaue Information der beteiligten Anästhesisten über etwaige Umbaumaßnahmen. Zudem muss das Bewusstsein für die Lachgasproblematik geschärft werden. Außerdem gilt es die Sicherheitssysteme weiterzuentwickeln, damit Lachgaskomplikationen sowohl in einer Klinik als auch landesweit besser erfasst und analysiert werden können. Dies könnte neben besserer Vernetzung der Fehlererfassungssysteme und Rückgriff auf Datenbanken der Versicherungen nach Haftpflichtprozessen auch den direkten Einbezug von Experten in die Unfallaufklärung beinhalten.

Abstract

Despite inspiratory oxygen fraction measurement being regulated by law in the European norm EN 740, fatal errors in nitrous oxide delivery still occur more frequently than expected, especially after construction or repair of gas connection tubes. Therefore, if nitrous oxide is to be used further in a hospital, all technical measures and system procedures should be employed to avoid future catastrophes. Among these are measurement of the inspiratory oxygen fraction (FIO2) and an automatic limitation of nitrous oxide. Also all anaesthetists involved should be informed about repair or construction of central gas supply tubes. Additionally, more awareness of this problem in daily routine is necessary. Furthermore, a system of detecting and analysing errors in anaesthesia has to be improved in each hospital as well as in the anaesthesia community as a whole. Measures for a better „error culture” could include data exchange between different critical incident reporting systems, analysis of closed claims, and integration of medical experts in examination of recent catastrophes.

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Interessenskonflikt

Kein Autor hat einen Interessenskonflikt bezüglich der im Manuskript vorgestellten Verfahren, Medikamente und Methoden.

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Authors and Affiliations

  1. Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich

    H. Herff, P. Paal, K.H. Lindner, A. von Goedecke, C. Keller & V. Wenzel

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  1. H. Herff
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  2. P. Paal
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  3. K.H. Lindner
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  4. A. von Goedecke
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  5. C. Keller
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  6. V. Wenzel
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Correspondence to H. Herff.

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Dieses Projekt wurde lediglich aus Mitteln der Abteilung gestaltet.

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Herff, H., Paal, P., Lindner, K. et al. Lachgasbedingte Todesfälle. Anaesthesist 57, 1006–1010 (2008). https://doi.org/10.1007/s00101-008-1434-7

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  • DOI: https://doi.org/10.1007/s00101-008-1434-7

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