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중앙배관시설에서 산소기통대신 질소기통이 연결되어 발생한 저산소증
한영진,이상귀,고성훈,강승관 대한마취과학회 1999 Korean Journal of Anesthesiology Vol.36 No.2
We present a case of hypoxia which occurred during the onset of general anesthesia in a small hospital. It was found that one of the oxygen tank which formed the central pipeline gas supply had been erroneously replaced by a nitrogen tank. Lack of strict observance of Compressed Gas Supply Standards by the gas supplier and the hospital personnel allowed it. We also emphasize that the oxygen analyzer should be counted as an essential monitor in every anesthesia. Oxygen analyzer detects the supply of intraoperative hypoxic gas admixture promptly and effectively. (Korean J Anesthesiol 1999; 36: 370∼373)