Lessons from Bankstown

A report has been released by the Chief Medical Officer, NSW, outlining the finding of the recent events in Bankstown-Lidcombe Hospital, where a baby died following a neonatal resuscitation. There are lessons to be learned for all of us from this tragic case. Here, we summarise the findings. The full report can be read here.


What happened?

In June 2016, a neonate (Baby 1) was resuscitated in the operating theatres. The baby survived, but there was an unexpected poor outcome and so a RCA (Root Cause Analysis investigation) was initiated. A few weeks later, in July 2016, a second baby (Baby 2) was resuscitated in the same operating theatre. The baby tragically died. This case was referred to the coroner and consequently the police became involved.

The day after the death of Baby 2, a paediatrician requested testing of the gas outlets in this operating theatre. It was tested one week later and it was found that the oxygen outlet was emitting nitrous oxide.


When were the outlets initially installed?

18 months earlier, the hospital was using oxygen cylinders for neonatal resuscitation. On one occasion, a baby required resuscitation in the birthing suit using the oxygen cylinders, but the oxygen tank ran out. The baby had to be transferred to Special Care where they had more oxygen available. An RCA was instigated in this case, and consequently it was decided to install piped oxygen to the birthing suite and also to the neonatal resuscitation area in theatres.

This was installed in July 2015.


How many babies were resuscitated in this theatre?

Although the gas outlet was installed in July 2015, the outlet was not used in this theatre (one of 8 theatres) until June 2016 when Baby 1 was born. After checking records retrospectively, only Baby 1 and Baby 2 were resuscitated with gas in this theatre.


How was nitrous oxide connected to the oxygen outlet?

The report indicates two areas where mistakes occurred: the procedure for installing the gas; and the procedure for verifying the gas post-installation.

The gas was installed by an independent company. I am not an engineer, but my understanding of the process is as follows:

  • when installing a new gas outlet, the engineer is required to isolate only the gas required
  • the pipe for this gas is then drained of pressure
  • when the pipe is then cut to make a new connection there will be no pressurised gas in that pipe
  • if there is any pressure detected, then that indicates that the wrong gas is being attached to the new connection

In this case, rather than isolating just the oxygen gas, the engineer isolated all the gases, including nitrous oxide. Therefore, when cutting the pipe, there would be no indication that the wrong pipe had been cut.

Secondly, after installation the gas should have been verified as being oxygen. This verification should have been witnessed by a member of clinical staff who is experienced in delivering medical gases. The engineer has noted twice on the forms that the oxygen was tested and was 100% oxygen. This cannot have been the case as the actual reading would have been 0% oxygen. No clinical staff verified or witnessed this testing.


What are the report findings and recommendations?

The report identifies issues with the engineering process and also the governance within the hospital.

The RCA made a recommendation for submission to the Australian Resuscitation Council to review the existing neonatal resus algorithm. It recommends that a section be added about unexpected hypoxia which includes consideration of the gas outlets.


This is a tragic case and must be very stressful for all those involved. As clinicians who are frequently involved in neonatal resus, we have a process for reviewing equipment when faced with unexpected hypoxia during neonatal resuscitation. From now on, we should consider gas outlets as part of this trouble-shooting process and this may need to include a final step of disconnecting the baby from the piped gases and trialling on a self-inflating bag in room air.

RINSEA terápiás hipotermia a kezdeti lelkesedés (Holzer 2002)…


A terápiás hipotermia a kezdeti lelkesedés (Holzer 2002) óta egyre kevésbé tűnik előnyösnek. Először az derült ki, hogy 36 fok legalább olyan jó, mint a 32 (Nielsen, 2013). Sokan azt gondolták, azért nem sikerült bizonyítani a hipotermia előnyét, mert nem elég korán kezdjük meg a keringésleállást követőn, így a károsodás már megtörténik, mire a hűtést megkezdjük.A friss RINSE vizsgálatban már a CPR alatt megkezdték a hideg infúzióval való hűtést (átlag 647ml), de így is korán abbahagyták a vizsgálatot, mert úgy tűnt a hipotermia rontotta a ROSC esélyét és nem javított a neurológiai kimenetelen sem.

2002 Holzer


2013 TTM


2016 RINSE


Emergency Coronary Angiography After Out-of-Hospital Cardiac Arrest

    A 70 year old woman suffered an out of hospital cardiac arrest whilst playing golf. She received bystander cardiopulmonary resuscitation and two shocks from an automated external defibrillator which restored spontaneous circulation. She was intubated at the scene  and arrived in the resuscitation department cardiovascularly stable, well oxygenated and unconscious in the context of propofol […]

Magensonden legen leicht gemacht!

Hin und wieder will es einfach nicht funktionieren. Auch solche, großteils einfachen Prozeduren wie eine Magensonde am intubierten Patienten zu legen, kann mitunter Schwierigkeiten bereiten. Das letzte Mal als ich partout eine Magensonde nicht korrekt positionieren konnte, zeigte mir ein Oberarzt folgenden genialen – weil simplen – Trick:
Einfach einen Endotrachealtubus als Schiene für die Magensonde verwenden!


  • Magensonde
  • Laryngoskop
  • Gleitmittel
  • Schere
  • Tubus (je größer umso leichter rutscht die Magensonde durch. 7,5-8 passt meistens)

Schritt 1: Konnektor für den Beatmungsbeutel vom Tubus entfernen

Schritt 2: Tubus längs durchtrennen

Schritt 3: Tubus und Magensonde mit Gleitmittel eingelen

Schritt 4: in den Ösophagus intubieren (macht man ja angeblich hin und wieder)

Schritt 5: Magensonde über den Tubus schieben

Schritt 6: korrekte Position verifizieren

Schritt 7: Magensonde bleibt, Tubus seitlich lösen und entfernen


FullSizeRender IMG_3404 IMG_3408 IMG_3409 IMG_3410 IMG_3411


Die Kollegen von Scancrit haben diese Methode ebenfalls schon mal beschrieben und anscheinend wurde sie auch schon publiziert (100%ige Erfolgsrate):

Kwon OS,Cho GC,Jo CH,Cho YS. Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED.Am J Emerg Med. 2015 Feb;33(2):177-80. doi: 10.1016/j.ajem.2014.11.004. Epub 2014 Nov 13.


Viel Spaß beim Ausprobieren!

P.S.: Natürlich kann man diese Methode ebenso bei der Platzierung von Ösophagussonden etc. anwenden.

How deep should I place my CVC?

All the hard parts are done in the placement of your central line. You nicked the vein and NOT the artery. The wire threaded smoothly. You got confirmation on your ultrasound. Now, you just insert the triple lumen in over the wire. Inserting a central line to the right depth on your first try without needing to adjust after your post-line confirmation chest x-ray takes some practice.
The goal is to get the tip of your catheter in the SVC above the level of the pericardial reflection. You should aim to get the catheter tip lying in the long axis of the SVC without any abutment of the vein. Too deep, and you risk erosion or perforation of surrounding vasculature. You even run the risk of arrhythmia if you go really deep into the heart chambers. Not deep enough, and your line may not effectively deliver meds, and it runs a higher risk of thrombus formation and infection.
The schematic below shows the potential zones for catheter tip positioning. Zone A represents the optimal area for left-sided central lines. At this level, the central line is more likely to lie parallel to the vessel walls. Zone B represents an optimal location for right-sided central lines. Since it’s a straighter shot on the right side, you don’t need to insert as deep to ensure the catheter lies parallel to the vessel wall. Left sided lines should avoid Zone B because the catheter tip has a higher likelihood of irritating the lateral wall of the SVC.
I was looking for a nice diagram indicating the optimal depths for each central line site (RIJ, LIJ, Subclavian, Femoral), but there actually isn’t a great one out there. I realize the reason for this is because patients come in all shapes and sizes. Well, mostly the same shape, but definitely different sizes (see picture below). If you insist on some numbers, a right-sided line can often be somewhere from 15-18. A left-sided line often can be up to 20. Consider whether your patient is a short elderly woman or a tall NBA player. These can vary significantly. Once you do a few with the same CVC kit but a few different sized patients, you get a much better sense of how deep you should be placing them.
For more tips and tricks on getting a great central line placement, check out EMCrit’s central line page.