Description of Event or Problem · 1
PT PRESENTED TO THE OPERATING SUITE FOR ARTHROSCOPIC SURGERY OF THE KNEE. AN ANESTHESIA SYSTEM CHECK WAS PERFORMED JUST PRIOR TO PT ARRIVAL. MONITORS WERE APPLIED AND PREOXYGENATION BEGAN FOLLOWED BY INTRAVENOUS INDUCTION. HAND AND BAG MASK VENTILATION BEGAN NORMALLY IN THE NOW APNEIC PT BUT AFTER A FEW BREATHS BECAME IMPOSSIBLE, ATTEMPTS TO IMPROVE MASK VENTILATION WERE TO NO AVAIL. THE ANESTHETIST PROCEEDED TO INTUBATE THE PT VIA DIRECT LARYNGOSCOPY WITH EASE AND WAS CERTAIN OF PROPER TUBE PLACEMENT. ATTEMPTS TO NOW VENTILATE THE PT VIA THE ENDOTRACHEAL TUBE WERE ALSO IMPOSSIBLE. AT THIS TIME THE OSTEOPATH WAS SUMMONED FOR ASSISTANCE. CHEST AUSCULTATION REVEALED WHEEZING BILATERALLY AND MARKEDLY DIMINISHED BREATH SOUNDS. AN END TIDAL CO2 WAVEFORM WAS PRESENT BUT SEVERELY DAMAGED. AN ATTEMPT TO VENTILATE THE PT VIA BAG COMPRESSION WAS MET WITH EXTREME RESISTANCE. A QUICK GLANCE AT THE ANESTHESIA CIRCUIT REVEALED THE PROBLEM. A SMALL WHITE CIRCULAR CAP THAT ATTACHES TO THE GAS SAMPLING PORT WAS INSIDE THE ELBOW THAT CONNECTS TO THE "Y" PORTION OF THE CORRUGATED TUBING. THIS CAUSED VIRTUALLY COMPLETE OBSTRUCTION. THE PROBLEM WAS RECTIFIED IN A TIMELY MANNER WITHOUT THE PT EXPERIENCING ADVERSE REACTIONS OR CHANGES IN VITAL SIGNS, OXYGEN SATURATION ETC. RPTR BELIEVES THAT WHEN POSITIVE PRESSURE BAG MASK VENTILATION BEGAN THE CAP WAS INITIALLY INSIDE THE "Y" PORTION OF THE CORRUGATED CIRCUIT ALLOWING NORMAL FUNCTION, AND THEN MIGRATED INTO THE ELBOW CAUSING OBSTRUCTION. IF HAND PRESSURE WAS ON THE BAG WHEN THE FACEMASK WAS REMOVED FROM THE PT PRIOR TO INTUBATION THE FAILURE TO DEFLATE WOULD HAVE HERALDED THAT THE ANESTHESIA SYSTEM WAS NOW SUDDENLY FAULTY. RPTR BELIEVES THAT THE CAP WAS PRESENT IN THE CIRCUIT AS RECEIVED FROM THE MFR AND NOT SOMEHOW PLACED INTO THE CIRCUIT ERRANTLY AT FACILITY. THE CIRCUITS ARE SUPPLIED AS SINGLE USE DISPOSABLE UNITS IN A SEALED PLASTIC BAG AND INSTALLED BY ANESTHESIA TECHNICIANS AT HOSP. CORRESPONDENCE WITH THE MFR REVEALED THIS TO BE THE FIRST REPORTED INCIDENT OF THIS MECHANISM OF OBSTRUCTION. RPTR CONCLUDES THAT ONE CAN NEVER BE TOO THOROUGH INSPECTING AND TESTING THE ANESTHESIA SYSTEM. DISMANTLING THE ELBOW FROM THE CORRUGATED CIRCUIT SHOULD BE PERFORMED ROUTINELY AND AN INTERNAL VISUAL CHECK OF THE LUMEN PERFORMED BECAUSE THE OPAQUE NATURE OF THE CIRCUIT MAKES VISUAL IDENTIFICATION OF DEBRIS DIFFICULT WHEN EXAMINED EXTERNALLY. IN THE EVENT THAT A SIMILAR OCCURRENCE IS EXPERIENCED RPTR SUGGESTS THAT HAND PRESSURE BE APPLIED TO THE BAG AND EXPOSE THE DISTAL END OF THE CIRCUIT TO ROOM ATMOSPHERIC PRESSURE. THIS WOULD RAPIDLY GIVE A CLUE AS TO WHETHER THE PROBLEM WAS WITH THE PT OR ANESTHESIA SYSTEM. A RSUSCITATOR SHOULD ALWAYS BE AVAILABLE WHILE ADMINISTERING ANESTHESIA IN THE EVENT OF SUCH OCCURRENCES AND THE PROBLEM IS NOT READILY IDENTIFIED OR EASILY CORRECTABLE. THIS CASE WAS UNUSUAL IN THAT THE OBSTRUCTION DEVELOPED SUDDENLY AND COMPLETELY AFTER NORMAL CHECKOUT AND FUNCTIONING AND AT A MOST INOPPORTUNE TIME.