Pneumothorax caused by anesthesia circuit misconnection

Abstract

Preoperative checking of the anesthetic equipment which is the primary responsibility of the nurse anesthetist is crucial for patient safety. There are many misconnection possibilities with circle system that can contribute to as highly as 35% of adverse anesthetic outcomes. A 32-year old man was admitted to the operating room (OR) for appendectomy. After the induction of anesthesia and beginning mask ventilation the anesthesiologist noticed that ventilation was not effective, therefore performed endotracheal intubation. The tracheal tube was connected to the Y piece and the mechanical ventilation was started by anesthesia machine. The lungs were not expanding effectively, therefore manual ventilation was began by an ambu bag. Beginning the manual ventilation the anesthesiologist realized an increased resistance against ventilation and an elevated airways pressure. The SpO2 fell to 79% and tachycardia was evident. Physical examinations were suggestive of pneumothorax that occurred within the first 4-5 minutes of starting machine ventilation. Rechecking the anesthesia machine revealed an error in the connection of the anesthesia circuit. We briefly review the current literature and give suggestions to eliminate these mismanagements in the operating room which can be life threatening.