Clear Plastic Causes Obstruction of Breathing Circuit

Anonymous by request

Letter to the Editor:

To the Editor:

After 10 uneventful ENT cases today, we had a near miss in the final case—a panendoscopy. I was supervising the room with a conscientious and capable CRNA who had done a quick pressure check of the circuit prior to moving in. The patient was induced and the anesthetist was unable to mask ventilate; however, intubation was easily accomplished with a 5.0 microlaryngeal tube. Visualization was considered to be a grade 1 view. We were still unable to ventilate. There were no breath sounds. I pulled the tube and attempted to mask ventilate unsuccessfully, so I reintubated with an 8.0 ETT and still was unable to ventilate. The surgeon took a quick look with a flexible scope, looking for possible subglottic obstruction, but upon disassembling the circuit, the y-piece separated inadvertently from the elbow, revealing a perfectly disguised piece of packaging plastic causing the obstruction. Upon reassembly, the patient was easily ventilated, and is, thankfully, no worse for the wear.

I have heard about similar occurrences in the past, but this was an eye opener for me. As I recreated the obstruction in PACU, I realized that if the plastic film was small enough, as this had been, there are no exposed ragged edges, and it is impossible to see the obstruction through the circuit.

I have always been cautious not to trap plastic when assembling circuits, but this part is preassembled. There are a lot of potential places between the manufacturer and the patient for a mishap to develop.

My suggestion is simple. Why don’t we pressure manufacturers to wrap circuit components in a visible but translucent colored plastic wrap, so that it is more visible if inadvertently trapped in the circuit? It should be a low cost solution to a patient safety issue. I’d like to hear your thoughts.

Name and city withheld by request.