Abstract

A patient was inadvertently overdosed with halothane during the nitrous oxide phase of anesthesia induction. During the subsequent 2$#00BD;-h resuscitation attempt, the oxygen via the anesthesia machine continued to be contaminated with 5% halothane. Brain death was pronounced when the patient may have been only very deeply anesthetized. The vaporizer had accidentally been left on the full ON position prior to the procedure. Poor design of vaporizer controls.and operator neglect combined to allow protracted patient exposure to the toxic concentration of halothane. The medical examiner has a critical role in the adequate management of anesthesia/surgery related deaths.

References

1.
Ament
,
R.
, “
Classification of Operating Room Mortality
,”
Anesthesia and Analgesia
, Vol.
39
,
1960
, pp.
158
166
.
2.
Minuck
,
M.
, “
Death in the Operating Room
,”
Canadian Anaesthesiology Society Journal
, Vol.
14
,
1967
, pp.
197
204
.
3.
Holland
,
R.
, “
Special Committee Investigating Deaths Under Anesthesia. Report on 745 Classified Cases, 1960–1968
,”
Medical Journal of Australia
, Vol.
1
,
1970
, pp.
573
594
.
4.
Harrison
,
G. G.
, “
Anaesthetic-Associated Mortality
,”
South African Medical Journal
, Vol.
48
,
1974
, pp.
550
554
.
5.
Anaesthetic Deaths in South Australia
,”
Medical Journal of Australia
, Vol.
1
,
1976
, p. 4.
6.
Epstein
,
R. M.
, “
Morbidity and Mortality from Anesthesia: A Continuing Problem
,”
Anesthesiology
, Vol.
49
,
1978
, pp.
388
389
.
7.
Nationwide Summaries of Pending Medical Malpractice Claims Involving Anesthesiologists
,”
Malpractice Digest
, July/Aug. 1974, p. 3.
8.
Harrison
,
G. G.
, “
Death Attributable to Anaesthesia
,”
British Journal of Anaesthesia
 0007-0912, Vol.
50
,
1978
, pp.
1041
1046
.
9.
Cooper
,
J. B.
,
Newbower
,
R. S.
,
Long
,
C. D.
, and
McPeek
,
B.
, “
Preventable Anesthesia Mishaps: A Study of Human Factors
,”
Anesthesiology
, Vol.
49
,
1978
, pp.
399
406
.
10.
Gordh
,
T.
and
Mostert
,
J. W.
, “
Anesthetic Accidents: Case Studies
,”
International Anesthesiology Clinics
, Vol.
16
,
1978
, pp.
1
194
.
11.
Recent Studies Provide Added Data on Anesthesia Mishaps
,”
Malpractice Digest
, July/August, 1979, pp.
2
3
.
12.
Mazzia
,
V. D. B.
, “
Comments on Forensic Anesthesiology
,” in
Legal Medicine Annual
.
Appleton-Century-Crofts
,
New York
,
1974
, pp.
175
188
.
13.
Harrison
,
G. G.
, “
A Classification for Deaths Associated with Anaesthesia and an Evaluation of Autopsy in Their Assessments
,”
Journal of Forensic Medicine
, Vol.
15
,
1968
, pp.
71
84
.
14.
Munson
,
W. M.
, “
Cardiac Arrest: Hazard of Tipping a Vaporizer
,”
Anesthesiology
, Vol.
26
,
1965
, p. 235.
15.
Safar
,
P.
and
Galla
,
S. J.
, “
Overdose with Ohio Halothane Vaporizer
,”
Anesthesiology
, Vol.
23
,
1962
, pp.
715
716
.
16.
Sharrock
,
N. E.
and
Gabel
,
R.
, “
Inadvertent Anesthetic Overdose Obscured by Scavenging
,”
Anesthesiology
, Vol.
49
,
1978
, pp.
137
138
.
17.
Kopriva
,
C. J.
and
Lowenstein
,
E.
, “
An Anesthetic Accident: Cardiovascular Collapse from Liquid Halothane Delivery
,”
Anesthesiology
, Vol.
30
,
1969
, pp.
246
247
.
18.
Bjoraker
,
D. G.
, “
Inability to Shut Off a Halothane Vaporizer
,”
Anesthesiology
, Vol.
50
,
1979
, pp.
53
54
.
19.
Duncan
,
W. A. M.
and
Raventos
,
J.
, “
The Pharmacokinetics of Halothane (Fluothane) Anesthesia
,”
British Journal of Anaesthesia
 0007-0912, Vol.
31
,
1959
, p. 302.
20.
Rendall-Baker
,
L.
, “
Some Gas Machine Hazards and Their Elimination
,”
Anesthesia and Analgesia
, Vol.
55
,
1976
, pp.
26
33
.
21.
Everett
,
G.
,
Hornbein
,
T. F.
, and
Allen
,
G. D.
, “
Hidden Hazards of the McKesson Normatic Anesthesia Machine
,”
Journal of the American Dental Association
 0002-8177, Vol.
81
,
1970
, pp.
695
697
.
22.
Spencer
,
J. A. E.
and
Green
,
N. M.
, “
Suicide by Ingestion of Halothane
,”
Journal of the American Medical Association
 0098-7484, Vol.
205
,
1968
, pp.
702
703
.
23.
Spencer
,
J. D.
,
Raasch
,
F. D.
, and
Trefnz
,
F. A.
, “
Halothane Abuse in Hospital Personnel
,”
Journal of the American Medical Association
 0098-7484, Vol.
235
,
1976
, pp.
1034
1035
.
24.
Kaplan
,
H. G.
,
Bakken
,
J.
,
Quadracci
,
L.
, and
Schubach
,
W.
, “
Hepatitis Caused by Halothane Sniffing
,”
Annals of Internal Medicine
 0003-4819, Vol.
90
,
1979
, pp.
797
798
.
25.
Lowe
,
H. J.
, “
Flame Ionization Detection of Volatile Organic Anesthetics in Blood, Gases, and Tissue
,”
Anesthesiology
, Vol.
25
,
1964
, pp.
808
814
.
26.
Gladsden
,
R. H.
,
Risinger
,
B. H.
, and
Bagwell
,
E. E.
, “
Determination of Blood Halothane Levels by Gas Chromatography
,”
Canadian Anaesthesiology Society Journal
, Vol.
12
,
1965
, pp.
90
98
.
27.
Cervenko
,
F. W.
, “
Halothane in Blood and Tissues
,”
Proceedings of the Royal Society of Medicine
, Vol.
61
,
1968
, pp.
528
530
.
28.
Davies
,
D. N.
,
Steward
,
A.
,
Allott
,
P. R.
, and
Mapleson
,
W. W.
, “
A Comparison of Arterial and Arterialized Venous Concentrations of Halothane
,”
British Journal of Anaesthesiology
, Vol.
44
,
1972
, pp.
549
550
.
29.
Wolfson
,
B.
,
Kielar
,
L. M.
,
Lake
,
L.
,
Hetrich
,
W. D.
, and
Siker
,
E. S.
, “
Anesthetic lndex—A New Approach
,”
Anesthesiology
, Vol.
38
,
1973
, pp.
583
586
.
30.
Allott
,
P. R.
,
Steward
,
A.
, and
Mapleson
,
W. W.
, “
Determination of Halothane in Gas, Blood, and Tissue by Chemical Extraction and Gas Chromatography
,”
British Journal of Anaesthesiology
, Vol.
43
,
1971
, pp.
913
917
.
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