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Kwon J, Kang E, Shin S, Lee B, Ko M, Kim S, Lee S. Ventilation Difficulty Caused by Obstructed Heated Breathing Circuit. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050965. [PMID: 37241197 DOI: 10.3390/medicina59050965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
For perioperative hypothermia prevention, a heated, humidified breathing circuit equipped with a fluid-warming unit inside the inspiratory limb has been developed. We report a ventilation difficulty caused by an obstructed heated breathing circuit. Cotton surrounding the hot wire, temperature sensor, and fluid tubing in the distal inspiratory limb was irregularly thicker than that of a normal circuit and nearly blocked the lumen. Despite carrying out routine checks on the anesthesia workstation preoperatively, we failed to make a prediagnosis by omitting the flow test after changing the circuit. This case puts emphasis on a routine flow test with a meticulous examination of the heated breathing circuit before every procedure.
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Affiliation(s)
- Jiyeon Kwon
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Eunsu Kang
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Sunghyun Shin
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Byeongcheol Lee
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Myoungjin Ko
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Sehun Kim
- Department of Anesthesia and Pain Medicine, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Soojee Lee
- Department of Anesthesia and Pain Medicine, Inje University Busan Paik Hospital, 75 Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea
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Dwivedi D, Sethi N, Patnaik S, Singh R. Compromised Ventilation in an Infant Caused by a Defective Connector of Endotracheal Tube. J Indian Assoc Pediatr Surg 2019; 24:151-152. [PMID: 31105408 PMCID: PMC6417049 DOI: 10.4103/jiaps.jiaps_108_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Deepak Dwivedi
- Department of Anaesthesia and Critical Care, Command Hospital, Armed Forces Medical College, Pune, Maharashtra, India
| | - Navdeep Sethi
- Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
| | - Subhasish Patnaik
- Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
| | - Rajeev Singh
- Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
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Jain N, Bhagat V, Nadkarni M. Endotracheal tube connector defect causing airway obstruction in a child. Indian J Anaesth 2017; 61:1020-1021. [PMID: 29307913 PMCID: PMC5752775 DOI: 10.4103/ija.ija_524_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Yang KK, Lewis IH. Mask induction despite circuit obstruction: an unrecognized hazard of relying on automated machine check technology. ACTA ACUST UNITED AC 2015; 2:143-6. [PMID: 25612202 DOI: 10.1213/xaa.0000000000000026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Various equipment malfunctions of anesthesia gas delivery systems have been previously reported. Our profession increasingly uses technology as a means to prevent these errors. We report a case of a near-total anesthesia circuit obstruction that went undetected before the induction of anesthesia despite the use of automated machine check technology. This case highlights that automated machine check modules can fail to detect severe equipment failure and demonstrates how, even in this era of expanding technology, manual checks still remain essential components of safe care.
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Affiliation(s)
- Kamie K Yang
- From the Department of Pediatric Anesthesia, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Jain D, Bala I. Manufacturing defect of endotracheal tube connector: A cause of airway obstruction. J Anaesthesiol Clin Pharmacol 2014; 30:583-4. [PMID: 25425801 PMCID: PMC4234812 DOI: 10.4103/0970-9185.142889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Divya Jain
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indu Bala
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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