Pre and post use check of anesthesia equipment- a useful ritual!

Komal GandhiMD¹, Divya Jain, MD²

¹Senior resident, ²Assistant professor

Department of Anesthesiology & Intensive Care, Postgraduate Institute of Medical Education & Research, Chandigarh, (India)

Key words: Anesthesia;Electronic Equipment and Supplies; Equipment and Supplies; Equipment; Equipment Safety

Citation: Gandhi K, Jain D. Pre and post use check of anesthesia equipment- a useful ritual! Anaesth Pain & Intensive Care 2015;19(3):419

Sir,

Mishaps in the operating rooms due to device breakage are common occurrences. We would like to report an incidence of intraoral breakage of temperature probe due to pulling against buck teeth in prone position.

A young female patient having buck teeth was planned to undergo lumbar vertebral pedicle screw fixation in prone position. The probe in question (General Purpose Temperature probe, adult, 3 M, reusable, 400 Series, GE Healthcare Finland Oy) was inserted orally till mid esophagus level smoothly after intubating the trachea during the induction of anesthesia. The patient was placed in prone position with head settled on horseshoe shaped head rest. Temperature readings were within normal limits throughout the operation. At the end of surgery, the temperature probe was removed against little resistance felt in terminal part while patient was still in prone position. Patient was returned to supine position before extubation. While cleaning this temperature probe, the blunt tip was seen missing (approximately 3-4 mm segment when compared to an intact probe).

The head rest and areas around the operating table were examined for the broken missing tip. Before fluoroscope could be employed, laryngoscopy was done to check for missing tip which was found lying in the oral cavity and was successfully removed using Magill’s forceps.

Mechanical complications due to temperature probe e.g. probe entrapment, knotting, misplacement, bleeding etc. have been reported previously.^1-6A small missing tip if unnoticed could have dislodged into the respiratory or alimentary tract leading to life threatening complication. Through this case we would like to highlight the importance of strict enforcement of anesthesia workstation checklist including examining the intactness of monitoring probes before and after use.

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