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The Canadian veterinary journal = La revue veterinaire canadienne2013; 53(9); 978-982;

Near-fatal misuse of medical tape around an endotracheal tube connector during inhalation anesthesia in a horse.

Abstract: A 7-year-old gelded Irish sports horse weighing 650 kg was anesthetized on 2 consecutive days for lavage of a septic right radio-carpal joint. On both occasions the endotracheal tube connector, which had been bound in medical tape to produce an airtight seal, functioned as a unidirectional valve during mechanical ventilation, retarding expiration, imposing positive end expiratory pressure (PEEP), and probably continuous positive airway pressure (CPAP). The equipment dysfunction was not identified on either occasion despite close inspection prompted by progressive increases in airway pressure and thoracic distension. Whilst the PEEP and CPAP exerted unexpectedly modest cardiovascular effects and the horse recovered uneventfully on both occasions, the improvisation may have proven fatal in a higher-risk subject. A 7-year-old gelded Irish sports horse weighing 650 kg was anesthetized on 2 consecutive days for lavage of a septic right radio-carpal joint. On both occasions the endotracheal tube connector, which had been bound in medical tape to produce an airtight seal, functioned as a unidirectional valve during mechanical ventilation, retarding expiration, imposing positive end expiratory pressure (PEEP), and probably continuous positive airway pressure (CPAP). The equipment dysfunction was not identified on either occasion despite close inspection prompted by progressive increases in airway pressure and thoracic distension. Whilst the PEEP and CPAP exerted unexpectedly modest cardiovascular effects and the horse recovered uneventfully on both occasions, the improvisation may have proven fatal in a higher-risk subject. Résumé Un hongre de sport Irlandais âgé de 7 ans pesant 650 kg a été anesthésié deux journées consécutives pour le lavage d’une articulation radio-carpienne droite septique. Lors des deux instances, le raccord du tube endotrachéal, qui avait été attaché à l’aide de ruban adhésif médical pour produire une fermeture hermétique, a servi de valve unidirectionnelle durant la ventilation mécanique, retardant l’expiration, imposant une pression positive en fin d’expiration et probablement une ventilation spontanée en pression positive continue. La défaillance de l’équipement n’a pas été identifiée dans l’une ou l’autre de ces instances, malgré une inspection minutieuse suscitée par des hausses progressives de la pression des voies aériennes et un gonflement thoracique. Même si la pression positive en fin d’expiration et la ventilation spontanée en pression positive continue ont eu des effets cardiovasculaires modestes inattendus et que le cheval s’est rétabli sans incident lors des deux instances, l’improvisation aurait pu s’avérée mortelle chez un sujet présentant des risques plus élevés.(Traduit par Isabelle Vallières).
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Publication Date: 2013-03-02 PubMed ID: 23450862PubMed Central: PMC3418784
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Summary

This research summary has been generated with artificial intelligence and may contain errors and omissions. Refer to the original study to confirm details provided. Submit correction.

This research discusses an incident during anesthesia where subpar equipment positioning led to potentially dangerous side effects for an Irish sports horse. The improper use of medical tape on an endotracheal (within the trachea) tube connector potentially could result in a life-threatening situation in higher risk subjects, despite having understated effects on the test subject.

Research Context

  • This research is based on a field study of anesthesia application with improper equipment positioning in a horse. The primary subject of this study was an Irish sports horse which was anesthetized twice over two consecutive days for the procedure of joint lavage cleaning of a septic right radio-carpal joint.
  • The endotracheal tube connector used during the process to facilitate the horse’s breathing was improperly fixed with medical tape. The purpose of the tape was to produce an airtight seal, but instead it impacted the connector’s functionality, converting it into a unidirectional valve.

Research Outcomes and Observations

  • During both anesthetization procedures, the unideal setup led to unexpected outcomes. As the valve started to function unidirectionally, it slowed down the expiration process or the release of breath. It imposed a Positive End Expiratory Pressure (PEEP) and probably a Continuous Positive Airway Pressure (CPAP) on the horse.
  • This equipment dysfunction was not identified on either day of operation. The anomaly was only noted following careful examination prompted by progressive increases in the horse’s airway pressure and thoracic distension or swelling of the chest area.

Significance and Conclusions

  • The research concludes that despite the horse recovering without any complications, it was an unforeseen condition impacting the breathing process. The effects of PEEP and CPAP on the horse were unexpectedly modest, and the horse showed no obvious signs of discomfort even with increased airway pressure and thoracic distension.
  • The primary concern raised through this research is regarding high-risk subjects. Considering that the unidirectional valve could have a more severe or potentially fatal outcome under different circumstances, this research stresses the importance of proper equipment setup and inspection during such procedures.

Cite This Article

APA
Gregson R, Clutton RE. (2013). Near-fatal misuse of medical tape around an endotracheal tube connector during inhalation anesthesia in a horse. Can Vet J, 53(9), 978-982.

Publication

The Canadian veterinary journal = La revue veterinaire canadienne
ISSN: 0008-5286
NlmUniqueID: 0004653
Country: Canada
Language: English
Volume: 53
Issue: 9
Pages: 978-982

Researcher Affiliations

Gregson, Rachael
  • Royal (Dick) School of Veterinary Studies, Division of Veterinary Clinical Sciences, The University of Edinburgh, Equine Hospital, Easter Bush Veterinary Centre, Midlothian, United Kingdom. rachael_gregson@hotmail.com
Clutton, R Eddie

    MeSH Terms

    • Anesthesia, Inhalation / adverse effects
    • Anesthesia, Inhalation / instrumentation
    • Anesthesia, Inhalation / methods
    • Anesthesia, Inhalation / veterinary
    • Animals
    • Continuous Positive Airway Pressure / instrumentation
    • Continuous Positive Airway Pressure / methods
    • Continuous Positive Airway Pressure / veterinary
    • Horse Diseases / surgery
    • Horses
    • Male
    • Positive-Pressure Respiration
    • Respiration, Artificial / instrumentation
    • Respiration, Artificial / methods
    • Respiration, Artificial / veterinary

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