BARALYME CARBON MONOXIDE

Description of Event or Problem

WHILE UNDERGOING SURGERY, PT DEVELOPED HIGH CO LEVEL-CARBOXHYGB OF 58. THE INVOLVED ANESTHESIA MACHINE HAD NOT BEEN USED FOR A PERIOD OF 36 TO 48 HOURS. THE PT SUFFERED NO UNTOWARD EFFECTS. REPORTS WERE MADE IMMEDIATELY TO THE DEPT OF HEALTH. THE ANESTHESIA MACHINE WAS TAKEN OUT OF SERVICE. A MEDWATCH REPORT WAS IMMEDIATELY MADE TO THE MFR OF THE MACHINE. THEY HAVE SINCE CALLED AND HAVE STATED THAT THEY FELT THE CAUSE OF THE PROBLEM WAS CARBON MONOXIDE. ONGOING INVESTIGATION HAS RESULTED IN THE CONCLUSION THAT THE EVENT WAS A RESULT OF THE REACTION BETWEEN DRY CARBON MONOXIDE AND DESFLURANE. THE CANISTER OF CARBON MONOXIDE INVOLVED HAVE BEEN SENT TO DR FOR FURTHER TESTING.