Adjustable Pressure Limit Valve Failure During Intraoperative Care: A Case Report

One of the many safety features of modern day anesthesia machines is the adjustable pressure limiting (APL) valve. This device regulates pressure within the anesthesia circuit during manual ventilation with the anesthesia bag. We report an unusual case where a crack in the APL valve allowed release...

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Bibliographic Details
Published inA&A practice Vol. 13; no. 7; p. 257
Main Authors D'Mello, Ajay J, Raman, Vidya T, Tobias, Joseph D
Format Journal Article
LanguageEnglish
Published United States 01.10.2019
Subjects
Air Pressure
Elective Surgical Procedures
Heart Valve Diseases - therapy
Humans
Hydrocephalus - surgery
Infant
Intraoperative Care
Respiration, Artificial - instrumentation
Treatment Outcome
Ventriculoperitoneal Shunt
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Summary:One of the many safety features of modern day anesthesia machines is the adjustable pressure limiting (APL) valve. This device regulates pressure within the anesthesia circuit during manual ventilation with the anesthesia bag. We report an unusual case where a crack in the APL valve allowed release of pressure from within the circuit resulting in ineffective bag-valve-mask ventilation of an infant. The appropriate steps to prevent such issues are reviewed, and an algorithm to quickly identify such intraoperative problems is presented.
ISSN:2575-3126
DOI:10.1213/XAA.0000000000001045