An Unusual Incident of “Cannot Ventilate” Situation Due to a Broken Soda Lime Canister: A Case Report

Abstract

The circle breathing system enables rebreathing using a carbon dioxide absorbent. This case report presents a rare incident of ventilation failure in a 30-year-old male patient due to a broken unidirectional valve in a soda lime canister. Despite the anesthesia machine passing automated checks, a mechanical blockage from caked soda lime in the inner inspiratory chamber led to insufficient tidal volume delivery. The incident underscores the importance of performing manual breathing circuit checks after replacing the soda lime canister, as well as the need for heightened vigilance in detecting equipment malfunctions to maintain patient safety during anesthesia.