Hypoxic Gas Supply from Cross-Connected Pipelines Christian Bohringer, MBBS, Adam Guemidjian, and Garth Utter, MD, MSc | September 25, 2024

https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines Hypoxic Gas Supply from Cross-Connected Pipelines In this WebM&M Case, an 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to being administered nitrous oxide instead of oxygen following a maintenance error by an inadequately trained employee. The patient was transferred to the intensive care unit (ICU) on a ventilator but remained unresponsive and died. The commentary discusses several approaches to improving patient safety during anesthesia administration in the surgical suite, such as use of oxygen analyzers and considering hypoxic gas mixture as the cause for sudden deterioration.