Tips for responding to accidental loss of an endotracheal tube adaptor: A case report

Interruption of ventilation during general anesthesia can quickly result in life-threatening hypoxemia, especially without spontaneous breathing. We herein report our experience responding to accidental loss of an endotracheal tube adaptor during prone position surgery. The patient, a 55-year-old man, was in the prone position for drainage of abscesses in his lower leg. After the end of the surgical procedure, an attending anesthesiologist disconnected the endotracheal tube from the ventilator circuit to change the patient's position from prone to supine. However, during this process, a 15-mm universal adaptor that connected the endotracheal tube (with an internal diameter of 8.0 mm) to the ventilator circuit accidentally became detached and went missing. As a result, the anesthesiologist could not reconnect the endotracheal tube to the ventilator circuit, leaving the patient temporarily unventilated. Therefore, the anesthesiologist immediately inserted the distal end of the endotracheal tube into the L-shaped connector of the ventilatory circuit to a depth of approximately 1.5 cm, and gripped them both firmly with a nitrile-gloved hand to prevent air leakage. Ventilation was subsequently established at a flow rate of 6 L/min, and the capnography waveform was detected. From the moment the initial adaptor came off to the moment a new regular adaptor was attached, no hypoxemia occurred. The impromptu maneuver was effective in temporarily connecting the ventilator and the endotracheal tube, and we have also confirmed that it works with narrower endotracheal tubes. Thus, we hope that the extremely simple maneuver presented here will be helpful in the event of such an unanticipated crisis as the one in the current report.