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Inadvertent activation of a PEEP valve leading to potentially severe cardiopulmonary complications in a horse
Author(s) -
Cruz Benedetti IngaCatalina,
Argano Martina,
Küls Nina,
Rocchi Attilio
Publication year - 2017
Publication title -
veterinary record case reports
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.165
H-Index - 4
ISSN - 2052-6121
DOI - 10.1136/vetreccr-2016-000389
Subject(s) - medicine , capnography , respirator , anesthesia , airway , limiting , expiration , airway obstruction , respiratory system , mechanical engineering , materials science , engineering , composite material
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.