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• W1533366926 abstract "In this institution, we run our Intensive Care transport ventilator from an oxygen cylinder, using a pneuPAC regulator/valve assembly to connect the two. This assembly consists of an oxygen-specific pin-index yoke, a regulator and an oxygen-coded Schrader valve outlet. During the latter part of 1997, one of our assemblies went missing and was eventually discovered by an external service engineer at one of our local ambulance stations; it had presumably been misplaced during a transfer. Following a request from the senior sister, the item was returned and was put back into stock about a month ago. A patient was to have a CT scan and one of the assemblies was therefore located, attached to an oxygen cylinder and the ventilator cable plugged into it. The anaesthetist concerned noticed a hissing noise and, on examining the assembly, found that the valve outlet was not an oxygen-coded Schrader outlet, but a silver-coloured valve, which was found to accept the Schrader probe from any pipeline, including vacuum (1, 2Figs 1 and 2). The valve was given to our ITU engineer, who found that the valve assembly was not, in fact, ours, but was one belonging to the ambulance service, which had been returned by mistake. We contacted the ambulance service, who informed us that all of their valves are like this. We then contacted Pneupac, who told us that they supplied these valves to the various ambulance services as they were cheaper and because oxygen is the only gas used in an ambulance. They said that the East Anglian Ambulance Service had purchased about 50 of these units and that, nationally, they had sold several hundred. Side view of the Pneupac regulator assembly showing the industrial, non-coded valve (removed) next to a coded oxygen Schrader valve. Top view of the Pneupac regulator assembly showing the industrial, non-coded valve (removed) next to a coded oxygen Schrader valve. Oxygen is in fact not the only gas used in an ambulance; the neonatal transport vehicle used in this region uses air to supply its ventilator, as well as oxygen and in some regions ambulances carry Entonox. Misconnection may result in excessive concentrations of oxygen being given. There is also a hazard in hospital; any pipeline may be connected, with oxygen being given instead of the correct gas. If a vacuum line were connected, the 4-kPa outlet pressure may well explode the vacuum controller, which is only rated to much lower pressures. From the above case, it is all too obvious how easy it is for equipment to be swapped between locations and therefore all equipment used in any location should meet the safety standards expected elsewhere. The lesson to learn is to have all equipment checked on its return from an external site, and also before each use." @default.
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• W1533366926 date "1998-12-01" @default.
• W1533366926 modified "2023-09-26" @default.
• W1533366926 title "Universal Shrader outlets on oxygen regulators" @default.
• W1533366926 doi "https://doi.org/10.1046/j.1365-2044.1998.0716n.x" @default.
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