An unseen obstruction

A 9-year-old child required general anaesthesia for laparotomy. Surgery and intra-operative anaesthesia were uneventful. The child's trachea was extubated and oxygen was administered via a size-3 Intersurgical facemask (Wokingham, Berkshire, UK). Carbon dioxide was not observed on capnography and the child’s breathing pattern was clearly obstructed. Airway manoeuvres were performed with the addition of a small amount of positive end- expiratory pressure to counter any presumed laryngospasm. A second anaesthetist arrived at this point to start the next operating list and, standing adjacent to the first, noticed that fogging was occurring: not in the mask as it should but over the nose and mouth. This was un-observable from the first anaesthetist’s position at the head of the patient. The mask was removed and the plastic backing of a Skintact™ ECG electrode (Skintact, Gloucestershire, UK) was found adherent to the inside of the mask, perfectly occluding the internal aperture. It was removed, oxygen successfully delivered to the patient, with immediate resolution of the obstructed breathing. The child remained 99% saturated throughout and suffered no adverse sequelae. Anaesthesia related complications are not uncommon in the paediatric population [1], occurring at a rate of between 2.4% and 8.6% of anaesthetics, varying with age [2], with the highest complication rates in children under the age of three [3]. Marcus found that 42.5% of in-theatre incidents during paediatric anaesthesia were due to human factors, the most common of which were errors in judgement, followed by failure to check equipment [2]. The disastrous consequences of equipment failure was highlighted by the 2001 case from the Broomfield Hospital in Essex, where a 9-year-old child for routine minor surgery died as a result of an intravenous line cap that was occluding the anaesthetic circuit. This case, and ten others like it, prompted a formal police investigation (Operation Orcadian), a response from the Department of Health [4] and guidelines from the Association of Anaesthetists of Great Britain and Ireland [5]. Although we had checked our equipment at the beginning of the case in accordance with the published guidelines, the colourless ECG electrode backing, with residual adhesive, had been accidentally discarded into the tray intended for the mask and laryngoscope, coming into contact with the facemask and causing complete obstruction. Had a second pair of eyes, observing the events from a different angle, not been present, the problem may not have been resolved so quickly. To our knowledge this is the first time a case such as this has been reported and it highlights the need for constant vigilance, not just with equipment, but also when discarding unwanted items.