Heat in Anesthesia: Reports of accidental deaths

Explosions in the operation theatre...
The patient- a child with vegetative foreign body swollen and soft in the bronchus. The patient was induced with ethyl chloride ether and taken deep in third stage, third plane and handed over to the surgeon as the procedure was expected to take longer than usual. The surgeon started and removed the foreign body bit by bit. O2 was added through the nozzle provided on the bronchoscope. In the middle of surgery there was a bang the surgeon face scalded and hair burnt and the child lay dead. Cause: Explosion due to over heated bulb and oxygen.
In another instance, the patient was induced in the induction room intubated and wheeled into the operation theatre. As soon as the anesthesiologist pressed the reservoir bag he was thrown away from the machine with burns on his hand and the patient lay dead. The reservoir bag was blown to pieces. Cause – Static electric spark causing explosion
During visit to Shrirampur for an ENT camp at the end of the day the doctors had some questions for both of us- the ENT surgeon and anesthesiologist over dinner. They presented me with a case which had resulted in death on the operation table. The incident had taken place during the hot summer days. Patient was male13-14 years old; symptoms were: high temperature 2-3 days, acute abdomen. The patient was induced with ethyl chloride ether after proper atropinization. The operation started after intubation and patient was connected to the Flagg’s can. The patient developed severe convulsions and died after couple of convulsive episodes. They wanted me to explain the cause. It was a typical case of ether convulsion with all conditions contributing to the fatality. High temperature summer days, ordinary operation theatre (not air-conditioned), good atropine action, toxaemia, deep ether anaesthesia good for laparotomy. All these were text book conditions for ether induced convulsions. They wanted to know the method for avoiding this complication. My answer was simple– cool the patient, use ether 2% after Thiopentone Scoline induction intubation and using muscle relaxant and IPPR. In case you can avoid ether use N2O--O2 IPPR with small supplements of pethidine.