Anaesthetic machine warning

SIR, — An anaesthetic machine at one of our practices exploded on February 8, seriously injuring two members of staff. We believe the profession at large is unaware of the risk that they face when changing oxygen cylinders on anaesthetic equipment. We would like to alert col­leagues to this risk and to pass on the advice we have received to help avoid a repetition.

The incident in question arose when two of our staff were trying to fit a regu­lator to the top of an oxygen cylinder. For whatever reason, they found the equip­ment difficult to fit, and so used a spray lubricant to make the task easier. On the third attempt at tightening the regulator, the anaesthetic machine exploded, caus­ing burns to the veterinary surgeon pre­sent and seriously injuring the ear of the attending nurse.

A label on the cylinder does state that no lubricant should be used, but it is not prominent and it does not explain the risk associated with such lubricants. A few members of the profession who I spoke to did recall being warned not to use lubri­cants, but they were not aware of the con­sequences of so doing.

We called in a specialist to investigate the incident (General Anaesthetic Services) and they explained that the lubricant, under pressure during the fit­ting process, heats up and presents com­bustible material to escaping gas, enough to cause a severe explosion.

The immediate and urgent advice to all concerned is as follows:

•    Ensure all staff involved in the replace­ment of oxygen cylinders know that they must never use any kind of lubricant

on any part of the oxygen / anaesthetic equipment;

•   Always turn the oxygen on very slowly, listening for escaping gas. Turn it off immediately if oxygen escapes; and

•   If on a second attempt, gas continues to leak, remove the cylinder and select another one. Return the first one to the suppliers.

Following this advice should help to ensure that no further accidents occur. Our staff arc now recovering from this terrible experience, but they are very keen that we alert the profession at large to this ever-present risk.

Brian Pound, CVS, Unir C, Victorio                                                           Rood, Diss, Norfolk 1P22 4GA