Biomaterial Database

Leak in the breathing circuit: CO2 absorber and human error. 2010

Goneppanavar Umesh, and Kaur Jasvinder, and Roy Sagarnil

Department of Anaesthesiology, Kasturba Medical College, Manipal, 576104, India. drumeshg@yahoo.co.in

A couple of reports in literature have mentioned CO2 absorbers to be the cause for breathing circuit leak during anesthesia. Defective canister, failure to close the absorber chamber and overfilling of the chamber with sodalime were the problems in these reports. Among these, the last two are reports of human error resulting in problems. We report a case where despite taking precautions in this regard, we experienced a significant leak in the system due to a problem with the CO2 absorber, secondary to human error.

UI	MeSH Term	Description	Entries
D008875	Middle Aged	An adult aged 45 - 64 years.	Middle Age
D002245	Carbon Dioxide	A colorless, odorless gas that can be formed by the body and is necessary for the respiration cycle of plants and animals.	Carbonic Anhydride,Anhydride, Carbonic,Dioxide, Carbon
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000764	Anesthesia, Closed-Circuit	Inhalation anesthesia where the gases exhaled by the patient are rebreathed as some carbon dioxide is simultaneously removed and anesthetic gas and oxygen are added so that no anesthetic escapes into the room. Closed-circuit anesthesia is used especially with explosive anesthetics to prevent fires where electrical sparking from instruments is possible.	Anesthesia, Rebreathing,Closed-Circuit Anesthesia,Anesthesia, Closed Circuit,Anesthesias, Closed-Circuit,Anesthesias, Rebreathing,Closed Circuit Anesthesia,Closed-Circuit Anesthesias,Rebreathing Anesthesia,Rebreathing Anesthesias
D019300	Medical Errors	Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.	Medical Mistakes,Surgical Errors,Critical Incidents, Medical,Critical Medical Incidents,Errors, Medical,Errors, Surgical,Medical Error of Commission,Medical Error of Omission,Medical Errors of Commission,Medical Errors of Omission,Medical Mistake,Mistake, Medical,Mistakes, Medical,Never Event,Surgical Error,Wrong-Patient Surgery,Wrong-Procedure Errors,Wrong-Site Surgery,Commission Medical Error,Commission Medical Errors,Critical Incident, Medical,Critical Medical Incident,Error, Medical,Error, Surgical,Error, Wrong-Procedure,Errors, Wrong-Procedure,Event, Never,Events, Never,Incident, Critical Medical,Incident, Medical Critical,Incidents, Critical Medical,Incidents, Medical Critical,Medical Critical Incident,Medical Critical Incidents,Medical Error,Medical Incident, Critical,Medical Incidents, Critical,Never Events,Omission Medical Error,Omission Medical Errors,Surgeries, Wrong-Patient,Surgeries, Wrong-Site,Surgery, Wrong-Patient,Surgery, Wrong-Site,Wrong Patient Surgery,Wrong Procedure Errors,Wrong Site Surgery,Wrong-Patient Surgeries,Wrong-Procedure Error,Wrong-Site Surgeries
D019544	Equipment Failure Analysis	The evaluation of incidents involving the loss of function of a device. These evaluations are used for a variety of purposes such as to determine the failure rates, the causes of failures, costs of failures, and the reliability and maintainability of devices.	Materials Failure Analysis,Prosthesis Failure Analysis,Analysis, Equipment Failure,Analysis, Materials Failure,Analysis, Prosthesis Failure,Analyses, Equipment Failure,Analyses, Materials Failure,Analyses, Prosthesis Failure,Equipment Failure Analyses,Failure Analyses, Equipment,Failure Analyses, Materials,Failure Analyses, Prosthesis,Failure Analysis, Equipment,Failure Analysis, Materials,Failure Analysis, Prosthesis,Materials Failure Analyses,Prosthesis Failure Analyses