An unusual foreign body in the breathing circuit.

Sir,

Failure in properly checking equipment is a factor in many critical incidents. Proper checking of equipment can help prevent equipment-related morbidity and mortality, improve preventive maintenance, and educate the anesthesia provider about equipment. Unfortunately, failure to perform a proper check before use is common.[1] We encountered an unusual foreign body in the breathing circuit and felt the need to re-emphasise the importance of the cockpit drill before induction of anesthesia.

There are numerous reports of obstruction of anesthesia breathing circuits by different foreign bodies.[23] However, we did not come across literature reporting breathing circuit obstruction caused by a cap of urobag tubing. While checking the anesthesia machine and breathing circuit, it was noticed that intra-circuit pressure did not decrease on opening the end of elbow connector to the atmosphere. On thorough inspection, no source of obstruction could be found, but on turning the circuit upside down and removing the elbow connector, a foreign body, which was, in fact, a cap of catheter end of urobag tubing, was noticed. It was in the Y-piece of breathing circuit with the open end abutting the bifurcation and blind end in the straight limb of Y-piece [Figure 1]. On initial inspection, the foreign body appeared as a continuation of the elbow connector because of the same color. It took some time to find the exact site of obstruction, which could had been sufficient to cause hypoxia.

Figure 1

Urobag cap in the Y-piece not easily identifiable

The exact reason for this unusual occurrence could not be determined. It was the first case on that day; moreover, on the previous day, three cases were managed in the same operation theatre uneventfully using the same circuit. One hypothesis is that nontechnical staff of the operation theatre, while cleaning at the end of the previous day, might have misconnected the urobag cap thinking it to be a part of the breathing circuit. A foreign body lodged in the elbow connector (a glass ampoule fragment after it was used to open a propofol ampoule) causing an impossible ventilation has been reported earlier.[4]

Although, the exact cause of this unusual incident could not be concluded, but its timely detection definitely avoided a potential catastrophe. We recommend that readers thoroughly follow the pre-use checkout guidelines to prevent critical incidents and improve patient safety. Lastly, the nontechnical staff of the operation theatre should be educated and trained about isolation and disposal methods of the items such as cap of urobag tubing or similar items, which have the potential to cause circuit obstruction.