Clinical Quiz

[piper77]

Thought I would add an experience that happened to me recently; after reading the "ventilate-or-not induction sequence" thread a few pages back. I enjoy reading other's experiences, and hope this one may offer some insight for future practice:

Did a machine check before my first case; thought the absorber was a bit dusky, so asked a technician to change it as I went to go see my patient. I returned a bit later to the room, saw the absorber was changed, did a pressure check on my circuit to ensure there were no leaks, and a few minutes later wheeled my patient into the room. Patient was 1 ppd X 40 years smoker; used bronchodilators prn but not for the past year or so. Big history GERD; RSI. Induction time, sux in, well ventilated, sat never drops below 100. Uncomplicated intubation with open cords. Cuff up......can't ventilate. No breath sounds. ET CO2 immediately 30 plus or so, and stayed there or higher. Trying to ventilate....making a little headway, bag is tight, airway pressures in the 50's and 60's trying to get a breath in. Thinking about the smoking....patient must be bronchospastic. Bronchodilators, Zantac, Benadryl, and epi....(patient concurrently showing signs of anaphylactoid reaction....marked rash, mild response to epi; was vasodilated). Slightly better ventilation, according to MD; CRNA notices the same improvement (now with ambu) on way to PACU, where patient is extubated after a while....lungs clear bilaterally on arrival in PACU, clean emergence and extubation. Sat never dropped below 100; ETCO2 in 30's. Anyone want to hazard a guess at the cause of the problem? I'll tell y'all in a little bit....:)

[deepz]

....Anyone want to hazard a guess at the cause......

Exhalation leaf valve blocked inadvertently when tech changed the CO2.

Or ... tech neglected to remove plastic overwrap on the absorber cartridge.

?

[athomas91]

i would have also guessed bronchospasm - but seeing as how you specifically mentioned the absorber change and circuit check - i am guessing something was wrong there.

[heartICU]

Or ... tech neglected to remove plastic overwrap on the absorber cartridge.

?

I agree with deepz - I think it was the plastic overwrap on the C02 absorbent. Had that happen in our OR once, but the CRNA caught it before induction.

[piper77]

good catch guys....as deepz knows....it was the overwrap. Good lesson for all of us in the room. Situation was confusing in that the patient did indeed have some type of histaminic response...and of course, the history. First time I encountered this...but I won't forget it...several CRNA's I talked to either experienced or heard of a similar incident. By the way....the plastic is virtually impossible to detect visually when in the cannister. I wonder if it might be useful to have colored stripes or such in the plastic.....the tech was a very experienced tech, too....felt awful. Anyway...thanks for your responses!