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To the Editor.
—A recent paper on some unusual anesthetic hazards by Milliken in the Archives (105:125-127, 1972) requires some comment as it would seem that those are not indeed "anesthetic hazards." From the description of the events leading to the discovery of the mishap it would appear that (1) There had not been an immediate check made of the proper placement of the tank. (2) Cyclopropane had never been used from the day the tank was installed to the time the machine was prepared for inspection. (This interval of time is not specified, but it could amount to 18 or even 36 months.)With reference to the first point, one should comment that there is no object in trying to involve the manufacturer. Whoever installs or replaces a new component in a system must also check for proper functioning of the system as a whole. With reference to the
Boba A. Anesthetic Hazard. Arch Surg. 1972;105(6):971. doi:10.1001/archsurg.1972.04180120146024
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