Korean J Anesthesiol.  2008 Dec;55(6):736-739. 10.4097/kjae.2008.55.6.736.

Ventilation impairment caused by upside-down connected unidirectional valves: A case report

Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea. icchoi@amc.seoul.kr

Abstract

We experienced a case of ventilation impairment resulted by the wrong-assembled unidirectional valves passed the automatic checkout of ventilator during general anesthesia. A 63-year-old man was scheduled for Ivor-Lewis operation due to esophageal cancer. After endotracheal intubation, ventilation impairment and abdominal distension were developed. No abnormal finding was found with bronchofiberoscopic examination. Suspecting anesthetic equipment failure, unidirectional valves were separated and they were proved to be connected upside-down.

Keyword

automatic check; machine malfunction; unidirectional valve; ventilation impairment; ventilator

MeSH Terms

Anesthesia, General
Equipment Failure
Esophageal Neoplasms
Humans
Intubation, Intratracheal
Middle Aged
Ventilation
Ventilators, Mechanical
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