Inadvertent activation of a PEEP valve leading to potentially severe cardiopulmonary complications in a horse
| Autor: | Attilio Rocchi, Martina Argano, Nina Küls, Inga-Catalina Cruz Benedetti |
|---|---|
| Rok vydání: | 2017 |
| Předmět: |
Capnography
business.product_category General Veterinary medicine.diagnostic_test 040301 veterinary sciences business.industry Flow regulator Horse 04 agricultural and veterinary sciences Peak inspiratory pressure Airway obstruction medicine.disease 0403 veterinary science 03 medical and health sciences 0302 clinical medicine 030202 anesthesiology Anesthesia During expiration medicine Respirator business PEEP Valve |
| Zdroj: | Veterinary Record Case Reports. 5 |
| ISSN: | 2052-6121 |
| DOI: | 10.1136/vetreccr-2016-000389 |
| Popis: | A five-year-old Austrian thoroughbred mare underwent anaesthesia and was mechanically ventilated using a Smith respirator L.A.-90. Shortly after commencing, capnography displayed a curve compatible with airway obstruction and haemoglobin saturation decreased progressively. Unexpectedly, positive-end expiratory pressure and peak inspiratory pressure reached 20 cm H 2 O and 50 cm H 2 O, respectively. The ventilator was disconnected and the patient ventilated manually, promptly correcting capnography and saturation. A later inspection of the ventilator identified two problems. The expiratory flow regulator, made of two overriding metal rings, was inadvertently rotated, preventing gas from escaping the system during expiration. Additionally, the poorly labelled knob limiting PIP had been left on 50 cm H 2 O. The authors describe a critical incident due to both, some specific features and limitations of the Smith Respirator L.A.-90, and the lack of familiarity of the anaesthetists with the ventilator. Implementing checklists may guide inexperienced users through the safe use of equipment. |
| Databáze: | OpenAIRE |
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