#272 Behind the Waveform: Critical Safety Implications of CO2 Sensor Selection

Anesthesia Patient Safety Podcast

Could your CO2 sensor be putting patients at risk? This eye-opening Rapid Response to Questions from our Readers episode explores a serious patient safety concern that every anesthesia professional needs to understand.
We dive into two troubling cases where patients under general anesthesia developed respiratory acidosis despite normal-appearing monitoring parameters. The culprit? A semi-quantitative CO2 sensor being used in an operating room setting where it was never designed to function safely. Through detailed case analysis, we uncover how the Nihon Kohden cap-ONE TG920P CO2 analyzer—which operates on the assumption that inspired air contains zero CO2—failed to detect dangerous rebreathing when CO2 absorbers became exhausted.
What makes this situation particularly concerning is that these semi-quantitative sensors display waveforms similar to their quantitative counterparts, creating a false sense of security. Dr. Amrutha Bindu Nagella shares her firsthand experience discovering the problem and her recommendations for preventing future incidents. We also hear Nihon Kohden's response, including their commitment to improving device labeling and safety warnings.
This episode highlights a critical knowledge gap that exists when technology moves between different clinical environments without proper understanding of its limitations. Whether you're an anesthesiologist, CRNA, anesthesia technician, or hospital administrator making purchasing decisions, this information could prevent a potentially dangerous situation in your operating room. Subscribe to the Anesthesia Patient Safety Podcast for more essential safety updates that keep your patients protected during anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/272-behind-the-waveform-critical-safety-implications-of-co2-sensor-selection/

© 2025, The Anesthesia Patient Safety Foundation

Kapitel

1. Introduction to CO2 Sensor Cases (00:00:00)

2. Case Studies of Respiratory Acidosis (00:02:10)

3. Semi-Quantitative vs Quantitative Sensors (00:05:40)

4. Nihon Kodan's Response (00:09:20)

5. Safety Recommendations and Conclusion (00:13:50)