Mechanical obstruction in the anaesthesia delivery-system mimicking severe bronchospasm.
We present a case where mechanical obstruction in the anaesthesia delivery system caused by plastic wrapping from a filter was misinterpreted as severe bronchospasm. The patient suffered severe hypoxia before the problem was solved by using a free-standing self-expanding ventilation bag. This near-fatal incident emphasises the importance of thorough equipment checking routines, rapid troubleshooting and how equipment failure may be misinterpreted as a medical complication. It also shows how transparent container material can become a medical hazard.
Aarhus
D
D
Department of Anaesthesiology, Rogaland Central Hospital, Stavanger, Norway.
Søreide
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E
Holst-Larsen
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H
D000328:Adult; D000768:Anesthesia, General / Q000295:instrumentation*; D000773:Anesthesia, Obstetrical / Q000295:instrumentation*; D001986:Bronchial Spasm / Q000175:diagnosis*; D003937:Diagnosis, Differential; D004868:Equipment Failure; D005260:Female; D005374:Filtration / Q000295:instrumentation; D006801:Humans; D000860:Hypoxia / Q000209:etiology*; D007431:Intraoperative Complications