Grave error in the OT - Pneumothorax caused by anesthesia ci
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CASE REPORT

A 32-year old man was admitted to the operating room (OR) for appendectomy. Except for leukocytosis, his initial laboratory findings were normal. In the OR preoperative blood pressure, electrocardiogram, and peripheral capillary oxygen saturation (SpO2) were normal. Anesthesia circuit tubes were connected to the old anesthesia machine (ALPHA DELTA®, Siare, Italy, 1975), circle system, and after a leak test by closing the adjustable pressure limiting (APL) valve, occluding the Y-piece, and pressurizing the circuit to 25 cmH2O with the oxygen flush valve, the induction of anesthesia was started by giving 2 mg midazolam, 150 µg fentanyl, 400 mg thiopentone, and 40 mg atracurium intravenously. Beginning mask ventilation the anesthesiologist noticed that ventilation was not effective, therefore performed endotracheal intubation. The tracheal tube was connected to the Y piece and the mechanical ventilation was started by anesthesia machine.....

http://www.apicareonline.com/pneumothorax-caused-by-anesthesia-circuit-misconnection/
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