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Departments of Anesthesiology, Kosair Childrens Hospital and the University of Louisville, Louisville, Kentucky
Address correspondence and reprint requests to Steve M. Auden, MD, Pediatric Anesthesia, N-65, Kosair Childrens Hospital, 231 E. Chestnut St., Louisville, KY 40202. Address e-mail to magidoc{at}yahoo.com
IMPLICATIONS: This case report describes a rare and potentially fatal anesthetic complication. It occurred during the care of a small premature infant as a result of improper use of medical equipment.
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