Case 2: Sudden Anesthesia System Failure

Abstract

A 1-year-old patient, American Society of Anesthesiologists (ASA) physical status II, is to undergo removal of a cerebral tumor under general anesthesia. An anesthesia machine and breathing system check is performed before the patient’s arrival. Noninvasive monitors are placed, and after preoxygenation the patient is anesthetized in a routine manner. Invasive monitors are placed, the operating table is turned 180°, and the operation begins. About 2 h into the operation, the surgeon requests that the operating table be elevated. Three to five minutes later, warning lights flash on the anesthesia machine (Narkomed 2 B, North American Drager). The warning indicates low minute volume, apnea, and no ventilation of the patient. The rotameters show adequate flow of oxygen and nitrous oxide, and the oxygen pipeline pressure is 50 psi.