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LETTER TO EDITOR
Year : 2013  |  Volume : 7  |  Issue : 1  |  Page : 99-100

Failure to ventilate: Technical error


Department of Anaesthesiology and Critical Care, Care Hospital, Bhubaneswar, Odisha, India

Correspondence Address:
Vivek Chowdhry
Department of Anaesthesiology and Critical Care, Care Hospital, Chandrasekharpur, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.109853

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Date of Web Publication30-Mar-2013
 


How to cite this article:
Chowdhry V, Rath A. Failure to ventilate: Technical error. Saudi J Anaesth 2013;7:99-100

How to cite this URL:
Chowdhry V, Rath A. Failure to ventilate: Technical error. Saudi J Anaesth [serial online] 2013 [cited 2020 Apr 6];7:99-100. Available from: http://www.saudija.org/text.asp?2013/7/1/99/109853

Sir,

A 22-year-old girl having history of brochial asthma with normal preanesthetic check-up and normal airway examination was posted for surgery for bilateral fibroadenama breast under general anesthesia. On the day of surgery, she was premedicated with fentanyl 50 μg and midazolam 2 mg 30 minutes before operation. In the operation theatre monitoring was started as per the American Society of Anaesthesiologist (ASA) standard. A venous cannula was inserted and was given 100% oxygen. After giving propofol 100 mg, she went into apnea immediately; we tried to ventilate the patient with bag and mask. While mask ventilation we found that the bag was too tight and the patient was not at all ventilating. Despite all efforts, it was not possible to ventilate the patient. Her saturation started dropping, immediately we intubated the patient and connected the anesthesia ventilator. Now the patient was nicely ventilating with peak airway pressure of 18 cm of H 2 O. On auscultation the chest was clear, no rhochi or spasm was detected and saturation rose to 100%. While investigating the cause of airway obstruction, we checked the circuit which was found to be absolutely obstruction free. While checking the mask, to our surprise we found that the cap of the ventilator circuit was fitting to the mask [Figure 1]. While investigating about the technical check-up before assembling the circuit, we found that the technician who had assembled the circuit, forgot to remove the cap from the ventilator circuit [Figure 2].
Figure 1: Cap fitting to the mask

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Figure 2: Cap obstructing the circuit

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There are numerous reports of obstruction of anesthesia breathing circuits by different foreign bodies and due to technical errors. [1],[2],[3] Most of these instances are due to inadequate check-up of the equipments. In our case the technician checked and assembled the circuit. Before induction of anesthesia, we checked the circuit for any leakage and obstruction by removing the mask, we found that the circuit was obstruction free as the cap, which was tightly fitting to the mask, also got removed with the mask. However, we did not check the mask. While again reassembling the circuit due to cap in the mask it caused total obstruction of the circuit leading to impossible ventilation. When, after intubation, we removed the mask from the circuit the cap remained in the mask and problem remained unnoticed. While thoroughly checking the equipments we finally found the obstructing cap fitting to the mask.

Here, we emphasize on sticking to the basics and thoroughly follow the preuse check guidelines to prevent critical incidents and improve patient safety. [4],[5] The nontechnical staff of the operation theatre should be educated and trained about correct assembling and preuse checks and lastly the anesthetist should check and confirm the proper working of the equipments before anesthetizing the cases.

 
  References Top

1.Roy K, Kundra P, Ravishankar M. Unusual foreign body airway obstruction after laryngeal mask insertion. Anesth Analg 2005;101:294-5.  Back to cited text no. 1
    
2.Foreman, MJ, Moyes DG. Anaesthetic breathing circuit obstruction due to blockage of tracheal tube connector by a foreign body-two cases. Anaesth Intensive Care 1999;27:73-5.  Back to cited text no. 2
    
3.Sethi AK, Mohta M, Sharma P. Breathing circuit obstruction by a foreign body. Anaesth Intensive Care 2004;32:139-41.  Back to cited text no. 3
    
4.Dorsch JA, Dorsch SE. Equipment checking and maintenance. In: Dorsch JA, Dorsch SE, editors. Understanding anaesthesia equipment. 5 th ed. New Delhi: Lippincott Williams and Wilkins a Wolters Kluwer Business; 2008. p. 931-54.  Back to cited text no. 4
    
5.Brockwell RC, Andrews JJ. Complications of inhaled anesthesia delivery systems. Anesthesiol Clin North America. 2002;20:539-54.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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