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Anesthesia Machine Close Call

Anesthesia Machine Close Call

Unexpectedly, the CO2 canister immediately dropped to the floor with a loud thud.”

Case Context   Provider Narrative   Lessons Learned

Case Context

Patient: middle-aged female, BMI 60
Diagnosis: abdominal pathology
Procedure: general laparoscopic surgery
PMH: HTN, Type 2 diabetes, hypothyroidism
Allergies: NKDA
PSH: unknown
Plan: General anesthesia, ETT

Provider Narrative

A middle-aged female presented for a general laparoscopic surgical procedure. Her past medical history included hypertension, Type II diabetes, hypothyroidism and a BMI of greater than 60. The surgery was to be performed by an attending physician and a surgery resident.  The surgical and anesthesia teams discussed the case in the preoperative area per protocol and lithotomy with steep Trendelenburg position was requested by the surgical team. The surgical time was estimated to be greater than 5 hours. The patient underwent a preanesthesia evaluation in the preoperative holding area. The airway assessment revealed a Mallampati Class 1, good neck extension with full range of motion, intact dentition, and a thyromental distance of 4 fingerbreadths. The patient was NPO after midnight and her lungs were clear to auscultation.


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