• A&A practice · Dec 2024

    Case Reports

    An Unusual Incident of "Cannot Ventilate" Situation Due to a Broken Soda Lime Canister: A Case Report.

    • Kanika Gupta, Priyanka Gupta, Saipavan Ganji, and Bishnupriya Mohapatra.
    • From the Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India.
    • A A Pract. 2024 Dec 1; 18 (12): e01878e01878.

    AbstractThe circle breathing system enables rebreathing using a carbon dioxide absorbent. This case report presents a rare incident of ventilation failure in a 30-year-old male patient due to a broken unidirectional valve in a soda lime canister. Despite the anesthesia machine passing automated checks, a mechanical blockage from caked soda lime in the inner inspiratory chamber led to insufficient tidal volume delivery. The incident underscores the importance of performing manual breathing circuit checks after replacing the soda lime canister, as well as the need for heightened vigilance in detecting equipment malfunctions to maintain patient safety during anesthesia.Copyright © 2024 International Anesthesia Research Society.

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