Failure of Anaesthetic Machine Automated Self-Check to detect massive leak in Ventilator Bellows

One of the many safety features of modern day anesthesia machines is the adjustable pressure limiting (APL) valve. This device regulates pressure within the anesthesia circuit during manual ventilation with the anesthesia bag. We report an unusual case where a crack in the APL valve allowed release of pressure from within the circuit resulting in ineffective bag-valve-mask ventilation of an infant. The appropriate steps to prevent such issues are reviewed, and an algorithm to quickly identify such intraoperative problems is presented.

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

Gupta,

Ganji

et al. 2024

A&A Practice

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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.

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Failure of Anaesthetic Machine Automated Self-Check to detect massive leak in Ventilator Bellows

Cited by 3 publications

References 6 publications

An Approach to Combining Medical Device Fault Analysis with Trusted Computing Forensics

An Approach to Combining Medical Device Fault Analysis with Trusted Computing Forensics

Adjustable Pressure Limit Valve Failure During Intraoperative Care: A Case Report

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

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