TY - CHAP M1 - Book, Section TI - Chapter 2. Practice Improvement and Patient Safety in Thoracic Anesthesia: A Human Factors Perspective A1 - Segall, Noa A1 - Mark, Jonathan B. A2 - Barbeito, Atilio A2 - Shaw, Andrew D. A2 - Grichnik, Katherine PY - 2012 T2 - Thoracic Anesthesia AB - A 46-year-old woman was scheduled for bronchoscopy and mediastinoscopy. Following uneventful induction of general anesthesia and tracheal intubation with an 8.0 mm endotracheal tube, bronchoscopy was performed. The upper thorax and neck were then prepped for mediastinoscopy using a standard iodine/alcohol surgical preparation solution (Iodine Povacrylex [0.7% available Iodine] and Isopropyl Alcohol, 74% w/w). The endotracheal tube was moved and secured to the right side of the patient's mouth, and the breathing circuit was secured to the side of the patient's head. Surgical incision and dissection were assisted with a standard electrosurgical unit. Approximately 10 minutes into the procedure, the anesthesiologist detected a breathing circuit leak. She checked all external connections and determined that the endotracheal tube pilot balloon was defective. To maintain effective ventilation, the endotracheal tube position was adjusted, additional air was added to the pilot balloon, and the circuit fresh gas flow was increased from 1 to 6 L/min. When the procedure was finished and the drapes removed, the anesthesiologist noted that the surgical drape on the right side of the patient's neck, near the endotracheal tube, was charred, and there was a 6 cm2 2nd and 3rd degree burn on the patient's right shoulder. In retrospect, an unusual smell was noted during the case by the operating room scrub nurse, but he attributed this to the leaking anesthetic gas and did not mention this to the rest of the surgical team. SN - PB - The McGraw-Hill Companies CY - New York, NY Y2 - 2024/11/08 UR - accessanesthesiology.mhmedical.com/content.aspx?aid=56782156 ER -