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I would like to report a critical incident which occurred whilst transporting a patient from ICU to the X-ray department. The patient was fully awake with a tracheostomy in situ and required CPAP of 10 cmH2O and an inspired oxygen concentration of 50%. He was transferred using an Oxylog 2000 portable ventilator (Drager, Hemel Hempstead, UK) attached to a CD Oxygen cylinder (BOC, Manchester, UK). When we arrived in X-ray we found that we were unable to disconnect the oxygen supply from the cylinder as the winged flange on the valve had come off (Fig. 3). There was a significant delay in locating a member of staff who was able to release the oxygen hose (using pliers), which resulted in the oxygen supply in the cylinder running out. We maintained oxygenation with a Mapleson C breathing circuit with the APL valve closed down to provide the necessary level of CPAP whilst providing constant reassurance to the patient.
The dangers posed to a critically ill patient due to malfunctioning equipment during a transfer should never be underestimated. As well as checking how full an oxygen cylinder is and performing a tug test of the Schrader valve, I would now advocate a ‘release test’ to ensure that the oxygen hose can be quickly disconnected if need be.