A problem with delivering CPAP during patient transport

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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.

Figure 3.

 Schrader outlet on CD cylinder without winged flange.

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.

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