Equipment related critical incident in anesthesia: leaking HME filter
Abstract
HME (heat and moist exchanger) filters are used ubiquitously in anesthesia and intensive care, especially during the current COVID-19 pandemic.1 Inherent adverse events associated with HME filters such as blockade, disconnections, increased dead space and delayed gas induction have been described and discussed.2-3 Here, we describe a case of an intraoperative leak of an HME filter that was detected timely preventing desaturation or related sinister consequences. The significance of systematic check of anesthesia-related equipment and keeping an open mind during critical incidents are further reinforced by this brief, yet interesting report.
Key words: Critical incidents; HME filter; Leak
Citation: Munasinghe BM. Equipment related critical incident in anesthesia: leaking HME filter. Anaesth. pain intensive care 2022;26(2): 265–266; DOI: 10.35975/apic.v26i2.1830
Received: January 10, 2022, Reviewed: January 17, 2022, Accepted: February 03, 2022
Acknowledgment: Dr. Nishanthan Subramaniam, Medical Officer in Anesthesiology & Intensive Care, for his involvement during the patient management.
