title: Mechanical obstruction in the anaesthesia delivery-system mimicking severe bronchospasm.
abstract: 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.
authors.affiliation: Department of Anaesthesiology, Rogaland Central Hospital, Stavanger, Norway.
authors.forename: D
authors.initials: D
authors.lastname: Aarhus
authors.forename: E
authors.initials: E
authors.lastname: Søreide
authors.forename: H
authors.initials: H
authors.lastname: Holst-Larsen
mesh_terms: 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