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
Y1  - 2012
N1  - 
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  - 2024/04/19
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=56782156
ER  -