A feline anaesthetic death associated with equipment incompatibility.

Abstract

BACKGROUND: A juvenile cat was anaesthetised for ovariohysterectomy. After intubation, the endotracheal tube was connected to an end-tidal CO(ETCO) in-line adapter and then to a non-rebreathing anaesthetic system. Immediately on connection to the non-rebreathing system, the patient developed abdominal distension. The endotracheal tube was removed and found to be supplying a continuous flow of oxygen while connected to the ETCOmonitor adapter and rebreathing system. The adapter was removed from the rebreathing line and the endotracheal tube re-inserted. Despite resuscitation attempts, the cat died. RESULTS: Necropsy revealed barotrauma to the lungs and separation of the diaphragm from the dorsal body wall, with retroperitoneal gas accumulation. Close inspection of the gas delivery system revealed the creation of a plastic-to-plastic seal between the internal fresh gas pipe of the non-rebreathing system and the ETCOadapter, preventing overflow of excess gas. CONCLUSION: Careful assessment of equipment compatibility before every anaesthetic event is essential.