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Canadian Journal of Anesthesia, Vol 41, 137-139, Copyright © 1994 by Canadian Anesthesiologists' Society

ARTICLES

Bain circuit occluded by foreign body

PR Wilkes and PA Lindsay
Department of Anaesthesia, University of Western Ontario, Victoria Hospital, London.

The purpose of this report is to describe a potentially hypoxic event which occurred during mask induction with the Bain circuit in a healthy. ASA I boy. Failure of induction occurred because a pop-off weight from a bubble bottle was lodged in the elbow connecting the Bain circuit to the mask and prevented gas flow. Pethick and Foex-Crampton Smith tests of the Bain circuit could also have missed this condition. Such an anaesthetic mishap could occur with any breathing circuit which is re-used. Although there was no serious misadventure, the potential for an hypoxic complication with either intra-venous induction of anaesthesia, or dislodging of the weight into the airway was significant. We conclude that the standard tests of system patency do not ensure safety.




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Copyright © 1994 by the Canadian Anesthesiologists' Society.