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Ch 17 · Monitoring & Equipment

Oxygen Failure in the OR

Pipeline & cylinder safety, what to do when the wall O₂ fails.

6 min read

Key Points

  • Daily machine check includes auxiliary O₂ cylinder, pipeline pressure ≥ 50 psi, FiO₂ analyzer calibration.
  • E-cylinder O₂: 660 L at 1900 psi. Tank time (min) = PSI ÷ 3 ÷ flow (L/min).
  • PISS (Pin Index Safety System) prevents attaching the wrong gas cylinder.
  • If O₂ fails: notify team, disconnect from machine, ventilate with AMBU + room air or backup tank — NOT the machine auxiliary (same source).
  • O₂ flush is inoperative without O₂ supply.

01Etiology of O₂ Failure

Loss of pipeline O₂: - Exhaustion of central O₂ supply - Obstruction of central O₂ supply line - OR O₂ shutoff valve closed - Disconnection of hose - Failure of O₂ regulator in machine

Faulty O₂ supply: - Crossed pipelines during construction - Incorrect gas hose connection - Non-O₂ cylinder at the O₂ yoke - Wrong gas in the O₂ cylinder - Broken flowmeter

02Daily Pre-Anesthesia Machine Check

  • Auxiliary O₂ cylinder + AMBU available and functioning
  • Pipeline gas pressure ≥ 50 psi
  • Spare O₂ cylinder mounted on machine > 50%
  • FiO₂ analyzer calibrated (should read 21% sampling room air); low-O₂ alarm audible
  • Vaporizers filled, capped
  • Circuit leak test, ventilator, scavenging system

03Cylinder Reference

GasE-Cylinder CapacityPressure (psi)Color (USA)Form
O₂660 L1900GreenGas
Air625 L1900YellowGas
N₂O1590 L745BlueLiquid + gas
N₂650 L1900BlackGas

N₂O is stored as a liquid — pressure stays at 745 until ~1/4 full; weigh the tank to assess.

Tank time: Time (min) = PSI ÷ 3 ÷ flow (L/min). E.g., O₂ at 430 psi running 5 L/min → 430 ÷ 3 ÷ 5 = 29 min.

04Safety Systems

Supply side: - Color-coded gas tanks (green = O₂ in US) - DISS (Diameter Index Safety System): non-interchangeable threaded connectors at the wall outlet - PISS (Pin Index Safety System): unique pin pattern on cylinder yoke - Quick connects for portable hoses

Anesthesia machine: - Flowmeter arrangement with O₂ closest to FGF outlet (Datex-Ohmeda, Draeger) → leak in O₂ flowmeter is hypoxic risk; leak in air/N₂O flowmeter is NOT (the mixture won't be hypoxic) - O₂:N₂O proportioning ("hypoxic guard") — prevents FiO₂ < 25% with N₂O via mechanical, pneumatic, or electronic linkage - Oxygen Supply Failure Protection Device ("fail-safe valve"): if O₂ pressure falls < 30 psi, N₂O cannot flow AND alarm sounds

Caveats: Proportioning can still deliver hypoxic mixtures with incorrect supply gas connections, defective components, downstream leaks, or addition of helium.

05Detection

  • Pressure gauges fall (pipeline, tank)
  • Low O₂ alarms (supply failure, FiO₂ analyzer)
  • Flowmeters fall (O₂ and other gases)
  • O₂ flush inoperative
  • Bellows fail
  • Apnea alarms (spirometer, capnograph)
  • Increasing O₂ flow makes the problem worse (drains the supply)
  • Hypoxemia, hypercarbia, arrhythmias, bradycardia, arrest

06Management

  1. Notify the surgeon, call for help, use the emergency manual.
  2. Verify the problem.
  3. Disconnect from the machine and ventilate with an AMBU bag and either room air or a backup tank.
  4. - Do NOT use the machine auxiliary O₂ — same source!
  5. Switch to TIVA if anesthesia must be maintained.
  6. Open the E-cylinder O₂ on the machine if pipeline is the problem (and pipeline is disconnected from supply).
  7. Calculate remaining tank time to plan.
  8. Get patient to an OR with working O₂ as soon as feasible.

Commonly missed steps: - Identifying empty O₂ E-cylinder before case start - Identifying easily accessible AMBU and backup cylinder

References & Further Reading

  1. 1

    Anesthesia Patient Safety Foundation (APSF). Newsletter and Safety Resources. apsf.org.

  2. 2
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

  3. 3
    Textbook

    Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

  4. 4
    Textbook

    Adriano A, Morris R, eds. 2021 CA-1 Tutorial Textbook (15th Ed.). Stanford University Medical Center, Department of Anesthesiology.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.