Bain circuit occluded by foreign body.
The purpose of this report is to describe a potentially hypoxic event which occurred during mask induction with the Bain circuit in a healthy. ASA I boy. Failure of induction occurred because a pop-off weight from a bubble bottle was lodged in the elbow connecting the Bain circuit to the mask and prevented gas flow. Pethick and Foëx-Crampton Smith tests of the Bain circuit could also have missed this condition. Such an anaesthetic mishap could occur with any breathing circuit which is re-used. Although there was no serious misadventure, the potential for an hypoxic complication with either intra-venous induction of anaesthesia, or dislodging of the weight into the airway was significant. We conclude that the standard tests of system patency do not ensure safety.
Wilkes
P R
PR
Department of Anaesthesia, University of Western Ontario, Victoria Hospital, London.
Lindsay
P A
PA
D000764:Anesthesia, Closed-Circuit / Q000009:adverse effects / Q000295:instrumentation*; D002675:Child, Preschool; D004867:Equipment Design; D004868:Equipment Failure; D004869:Equipment Safety; D006221:Halothane / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008397:Masks; D009609:Nitrous Oxide / Q000008:administration & dosage; D013499:Surface Properties
D009609:Nitrous Oxide; D006221:Halothane