To the Editor
An 11-year-old male was successfully induced for a cleft palate repair. After insertion of the endotracheal tube, a marked change in pulmonary compliance was noted. The endotracheal tube was replaced on 2 separate occasions and albuterol was administered because of a presumptive diagnosis of bronchospastic disease. When none of these therapeutic interventions were successful in ameliorating the change in compliance, a careful inspection of the anesthesia circuit was then conducted. This inspection revealed a partial obstruction from a Luer adaptor that was designed to fit over the carbon dioxide sampling port.
This Luer adaptor had been impacted in the elbow of the circuit. This occurred because of a process deficiency during the reprocessing of the anesthesia circuit. It should be noted that the hospital had decided to utilize a pasteurization process for reusing anesthesia circuit tubing and bags as a cost-containing measure. The obstruction in the elbow of the anesthesia circuit was not detected because the automated anesthesia machine checkout process for the Datex Ohmeda unit was proximal to the circuit elbow.
Fortunately, the partial obstruction in the anesthesia circuit was discovered in a timely fashion, and an untoward patient outcome was averted. Institutions considering changing from a disposable circuit to a reusable (pasteurization) process need to be sure that the reprocessing procedure assures that no pieces of equipment are inappropriately placed in the anesthesia circuit.
Kathy Nichols, MD
Dave Thomas, MD
C.J. Barker, RN