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Table of Contents
Year : 2019  |  Volume : 35  |  Issue : 1  |  Page : 139-141

Pediatric adverse airway event in gastroenterology suite during assisted ventilation with defective reservoir bag

Department of Anaesthesia and Critical Care, Armed Forces Medical College, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Web Publication16-Apr-2019

Correspondence Address:
Deepak Dwivedi
Department of Anaesthesia and Critical Care, Armed Forces Medical College, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_33_18

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How to cite this article:
Paul D, Dwivedi D, Sethi N, Sud S. Pediatric adverse airway event in gastroenterology suite during assisted ventilation with defective reservoir bag. J Anaesthesiol Clin Pharmacol 2019;35:139-41

How to cite this URL:
Paul D, Dwivedi D, Sethi N, Sud S. Pediatric adverse airway event in gastroenterology suite during assisted ventilation with defective reservoir bag. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2021 Jan 25];35:139-41. Available from:


Anesthesia providers are the backbone for all procedures inside as well as outside the operating suite. Nonoperating room anesthesia (NORA) poses a special challenge to the anesthesiologist in terms of safety and deliverance of anesthesia at such remote locations like gastroenterology center, interventional radiology, radiotherapy suites, computed tomography scan, etc.[1] Majority of cases at such remote locations are done under moderate sedation, but general anesthesia (GA) may be required depending on the age, physical status of the patient, position, and duration of the procedure. Gastrointestinal (GI) endoscopies in pediatric population are reported to have reversible nonfatal complication rate of 2.3%.[2]

We report a case of an adverse airway event in a healthy 4-year-old male child weighing 13 kg, who presented for elective upper GI endoscopy for hematemesis evaluation. Preanesthetic evaluation was done and patient was accepted under GA. There was no evidence of any hyper reactive airway. Fasting status and consent were ascertained on the day of procedure. Checklist for safe conduct of NORA was adhered to. Standard monitoring was instituted on arrival in the suite. Premedication was done intravenously with inj. midazolam 1 mg, inj. ondansetron 0.1 mg/kg, inj. glycopyrrolate 4 μg/kg, and inj. fentanyl 2 μg/kg. Child was induced with inj. propofol 2 mg/kg and airway secured with 4.5 mm ID microcuff tube after the administration of inj. atracurium 0.5 mg/kg. Maintenance of anesthesia was done with oxygen, air, and sevoflurane, while keeping minimum alveolar concentration of 1.2. Procedure was uneventful. However, while ventilating with the Jackson Rees (JR), circuit air leak was noticed due to a tear in the breathing bag. The breathing bag was replaced and assisted ventilation ensued. Suddenly compliance of the bag reduced and air way pressures went up to 28 cm H2O from the baseline of 16 cm H2O. Auscultation of the chest revealed severe bronchospasm with bilateral wheeze. Immediately four puffs of salbutamol from multidose inhaler were delivered through the endotracheal tube followed by inj. hydrocortisone 2 mg/kg IV and depth of anesthesia was maintained. To our surprise on inspecting the JR circuit, we found excess powder puffing out, once the adjustable pressure limiting valve was removed from the tail end of the reservoir bag of JR circuit. Corrective measures were taken and a new JR circuit was attached to the anesthesia workstation. The ventilation improved and the airway pressures normalized to 17 cm H2O with occasional wheeze. The patient was extubated and nebulized with 2.5 mg salbutamol in postanesthesia care unit. Patient had intermittent dry bouts of coughing and was discharged once the chest was clear.

Adverse respiratory event (ARE) is reported in 33% of pediatric population undergoing anesthesia.[3] ARE spectrum includes laryngospasm, stridor, prolonged coughing, and bronchospasm with oxygen saturation of <95%. Literature states a higher predictive value of ARE associated with risk factors ascertained from the family/child's history, with low predictive value associated with immunological markers of allergy. In our case, the history of atopy was negative and adverse respiratory event occurrence was a bizarre incident due to ingress of excess powder coating of the inner surface of the reservoir bag into the airway with each compression. External examination of the new reservoir bag did not reveal any abnormality, so the bag was not inspected from inside as it is not a routine practice. It was ascertained that there was excess powder inside the bag when the bag was split open [Figure 1]. Timely detection and management averted a crisis. Root cause analysis was done in the department, and as a policy, the new additional protocols directed toward the equipment check came in force for NORA. It included the circuits and equipment, which do not form integral part of the anesthesia work station, for example, JR circuit, Bain's circuit, and adult and pediatric resuscitator bag with alternate oxygen supply and suction. Daily serviceability report in respect of the anaesthesia machine at remote locations has been enforced to prevent mishaps.
Figure 1: Reservoir bag split opened showing excess powder coating the inner surface

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We recommend that ASA task force guidelines in respect to GI endoscopies suite[4] could be used in conjunction with robust protocols for regular anesthesia machine check and equipment for anesthesia delivery at such remote locations. Inclusion of safety compromise indicators at the GI suite as suggested by Borgaonkar et al.[5] when included as a part of dynamic program for quality improvement may limit the morbidity and adverse events.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Youn AM, Ko YK, Kim YH. Anesthesia and sedation outside of the operating room. Korean J Anesthesiol 2015;68:323-31.  Back to cited text no. 1
Dar AQ, Shah ZA. Anesthesia and sedation in pediatric gastrointestinal endoscopic procedures: A review. World J Gastrointest Endosc 2010;2:257-62.  Back to cited text no. 2
von Ungern-Sternberg BS, Ramgolam A, Hall GL, Sly PD, Habre W. Peri-operative adverse respiratory events in children. Anaesthesia 2015;70:440-4.  Back to cited text no. 3
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004-17.  Back to cited text no. 4
Borgaonkar MR, Hookey L, Hollingworth R, Kuipers EJ, Forster A, Armstrong D, et al. Indicators of safety compromise in gastrointestinal endoscopy. Can J Gastroenterol 2012;26:71-8.  Back to cited text no. 5


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