Extending the breathing circuit to its full length during pre-anesthesia checks is recommended to detect hidden leaks and prevent intra-operative equipment failure.
Standard leak tests may miss small circuit defects; this case leaves open whether routine full-length extension improves detection in anesthesia safety research.
It is a case of equipment failure in the form of leak in the breathing circuit which remained undetected during the pre-anaesthesia leak test done before the start of two different cases. The peri-operative course of the first case was uneventful. The second patient developed intra-operative bronchospasm. But suddenly the ventilator bellows collapsed and manual ventilation was possible only with intermittent oxygen flushes. Presence of a hissing sound prompted a check of the breathing system and revealed a hole 2.5 mm size in the expiratory limb of the silicone breathing hose. It probably got resulted when the circuit was stretched while trying to ventilate against an increased airway resistance and could be found. We recommend extending our breathing circuit to its the full length while checking to avoid such misses as a standard practice.
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Gupta et al. (2013) studied this question.
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