A strange case of leak: “leak in endotracheal tube due to manufacturing defect”.

Authors

  • Elena Díaz Álvarez Hospital resident. Anesthesiology and Resuscitation. Severo Ochoa University Hospital. Leganes, Madrid. Spain.
  • Juan José Correa Barrera Associate Physician. Anesthesiology and Resuscitation. Severo Ochoa University Hospital. Leganes, Madrid. Spain.
  • Vanessa Blázquez Calvo Associate Physician. Anesthesiology and Resuscitation. Severo Ochoa University Hospital. Leganes, Madrid. Spain.
  • Yasmina González Salvador Associate Physician. Anesthesiology and Resuscitation. Severo Ochoa University Hospital. Leganes, Madrid. Spain.

DOI:

https://doi.org/10.30445/rear.v15i8.1155

Keywords:

endotracheal tube defect, Patient safety, leak

Abstract

One of the fields where more progress has been made in recent decades is security. In the surgical setting, standardized protocols are particularly needed to increase detection capabilities. The surgical checklist includes material review. A case is presented in which high leaks were observed during mechanical ventilation after anesthetic induction. After reviewing the endotracheal tube, a perforation was observed. It is recommended to check the walls of the tube and the correct passage of air through it, checking only the pneumo-plug entails not detecting latent errors that can trigger a critical event.

References

- Gómez-Arnau Díaz-Cañabate JI, Molina Mendoza R, Martinez Fariñas P, Ramiro Ruiz Á. Calidad y seguridad asistencial en anestesia. En C. Tornero Tornero. Anestesia. Fundamentos y manejo clínico. Madrid: Ed Panamericana 2015. p 24-37.

- Lewer B. M. F., Karim Z., Henderson R. S. Large air leak from an endotracheal tuve due to a manufacturing defect. Anesth analg. 1997;85:944-9.

- Szekely S.M., Webb R.K., Williamson J.A. , Russell W.J. Problems related to the Endotracheal tuve: an analysis of 2000 incident reports. Anaesth Intens Care 1993; 21:611-616.

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Published

2023-09-05

How to Cite

Díaz Álvarez, E., Correa Barrera, J. J., Blázquez Calvo, V., & González Salvador , Y. (2023). A strange case of leak: “leak in endotracheal tube due to manufacturing defect”. Revista Electrónica AnestesiaR, 15(8). https://doi.org/10.30445/rear.v15i8.1155

Issue

Vol. 15 No. 8 (2023): Revista Electrónica de AnestesiaR

Section

Letters to Editor

License

Copyright (c) 2023 Revista Electrónica AnestesiaR

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