How Vital is a Preinduction Machine Check?

Lessons Learned After Failure to Ventilate

Nareg Gharibjaniansa, MS, MAS, MD, Kathleen Hurleya ,MS, MD, Vahe Tateosianb, MD

Introduction:
The anesthesia apparatus checkout recommended by the FDA is a vital component of any anesthesiologists morning schedule (1). This
checkout process includes procedures to evaluate the high and low pressure systems of the anesthesia machine and serves as a safety system
to avoid the inability to ventilate a patient subsequent to induction. Machine checks range from automated self-checkout functions to manual
pressure checks. In addition to internal components, each machine contains a CO2 absorber and circuit that can potentially cause failure. In the
1980s about 2% of the closed claims resulted from gas delivery equipment, with death and permanent damage occurring in 76% of the
outcomes (3). Of these cases the breathing circuit was found to be the most common cause. We present a case of the inability to ventilate a 42
y/o male admitted for elective lumbar decompression laminectomy.
Case Presentation:
A 42 y/o smoker with history of asthma was admitted for an elective lumbar decompression laminectomy. Upon arrival to the OR, he was kept
supine on his transport bed. The anesthesia machine had been inspected before the prior case according to the ASA / FDA guidelines (1).
Oxygen was administered with a standard face mask attached to the circuit of a Datex-Ohmeda Aestiva 5 machine (Ohmeda, Madison, WI) and
end tidal CO2 was detected. Anesthesia was induced with fentanyl, propofol, and rocuronium. Upon induction it was difficult to mask ventilate
the patient at which point the trachea was intubated using a video laryngoscope. The ETT was attached to the circuit and ventilation continued
to be difficult. Tidal volumes of approximately 65ml were obtained with vigorous ventilation. A concrete bag was observed with increasing
peak pressures greater than 50 cm H2O. Upon auscultation, distant B/L breath sounds were heard and a wide differential including
bronchospasm, chest wall rigidity, pneumothorax, mucous plug, and a kinked circuit were considered; appropriate treatments were not
curative. Treatments included administration of multiple rounds of albuterol, epinephrine and ketamine for potential bronchospasm, suctioning
of the endotracheal tube, and a visual inspection of the circuit for kinks. Help was called overhead and multiple Anesthesiologists arrived to the
OR. To rule out machine failure the patient was disconnected from the circuit and a backup self-filling manual ventilation bag was connected at
which point normal ventilation ensued and a normal CO2 tracing was visualized. The patient remained hemodynamically stable throughout the
episode. The case was canceled and the trachea was extubated with complete recovery.
Discussion:
We report an anesthesia machine failure similar to a case described by Ianchulev and Comunale (2). However, in our case it was caused by a
wrapped CO2 absorbent canister which had been replaced between cases without our knowledge. We were unable to ventilate the patient
during induction and subsequently went through a wide differential of potential causes which included bronchospasm, chest wall rigidity,
pneumothorax, mucous plug, and kinking of the circuit. Under the assumption that the trachea was initially intubated the Anesthesiologist
proceeded to address a possible bronchospasm with multiple doses of albuterol, epinephrine, and ketamine. Bronchospasm was on the
differential because of the high peak pressures, distant breath sounds, and history of smoking and asthma.
In addition chest wall rigidity was considered with the two main inciting causes being high dose narcotics as well as malignant hyperthermia.
Considering muscle relaxant was already administered upon induction and that rigidity is not usually the initial sign of malignant hyperthermia,
the care providers moved on to other potential causes. The ETT was quickly suctioned and was found to be dry. Ultimately, as was the case for
Ianchule and Comunale (2) a backup self-filling manual ventilation bag was utilized for normal ventilation. This was the first event of its kind at
our institution. Prior events noted in Anesthesia literature have cited cracked or open CO2 absorbers and overfilled canisters which would
result in failure of a positive pressure test (2,4).
Unfortunately, conducting a positive pressure leak test pre-induction with our presented scenario would have maintained a sustained pressure.
However, visualization of the breathing bag deflating and inflating would ensure continuity of the circuit. This event clearly illustrates why in
addition to a morning circuit and machine check every subsequent use of the machine should be preceded by a pressure test of the circuit and
visualization of the breathing bag deflating and inflating prior to induction. In addition, anesthesia technicians are now required to leave a
notice on the anesthesia machine if any changes have been made during the regular operating hours.
Conclusion:
In conclusion, the insertion of an unwrapped CO2 absorber can lead to inability to ventilate with a concrete bag. This underscores the
important of a pre-induction machine check along with visualization of the breathing bag deflating and inflating prior to induction and the
immediate availability of a self filling manual ventilation bag.
References:
1. Food and Drug Administration. Anesthesia apparatus checkout recommendations, 1993. Rockville, MD: Food and Drug Administration, 1993.
2. Ianchulev SA, Comunale ME. To do or not to do a preinduction check-up of the anesthesia machine. Anesth Analg 2005;101:774-6.
3. Caplan RA. Liability arising from anesthesia gas delivery equipment. ASA Newsletter 1998;62:7-9.
4. Ezaru CS. Letter. Preinduction Check-Up of the Anesthesia Machine. Anesth Analg 2006; 102:1585-98.