Unexpected Anesthetic Circuit Leak Attributed to Improper Use of a Tube Holder: A Case Report
Leaks involving the anesthesia circuit can cause significant complications including hypoxia and hypoventilation. We present a case of a circuit leak caused by damage to the corrugated tubing attributed to improper use of the tube holder. A 58-year-old male was scheduled for resection of a palatal tumor under an intubated general anesthetic. After successful nasotracheal intubation, the anesthesiologist inserted the corrugated tubing of the anesthetic circuit into the tube holder. A leaking sound was heard and a tear in the corrugated tubing was promptly discovered. The corrugated tubing of the anesthetic circuit presumably tore because it was inserted into the groove of the tube holder at an inappropriate angle with excessive force. Anesthesiologists should be aware of potential leaks if the anesthesia circuit is damaged, which may be caused by improper use of tube holders.
Tube holder and damaged anesthesia circuit tubing. (A) The tube holder used in this case. (B) The corrugated tubing used in this case with a red circle indicating the damaged area. (C) Enlarged view of the corrugated tubing with a red arrow indicating the tear.
Tube holder and tubing measurements. (A) Enlarged view of the tube holder showing the inner diameter of the tube holder groove measuring 18 mm at the entrance and 20 mm at the central portion. (B) Enlarged view of the corrugated tubing showing the outer diameter measuring 27 mm at the widest/convex and 19 mm at the narrowest/concave portions.
Experimental attempts to reproduce the damaged tubing. (A) Corrugated tubing inserted straight into the tube holder groove. The red dotted line shows the proper angle between the groove and the corrugated tubing. (B) Corrugated tubing positioned at a misaligned angle relative to the tube holder groove. (C) Corrugated tubing torn when excessive force used during insertion into the tube holder groove from the position shown in (B). The red arrow indicates the tear in the corrugated tubing likely caused by the edge of the groove.
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