Peer-reviewed veterinary case report
Near-fatal misuse of medical tape around an endotracheal tube connector during inhalation anesthesia in a horse.
- Journal:
- The Canadian veterinary journal = La revue veterinaire canadienne
- Year:
- 2012
- Authors:
- Gregson, Rachael & Clutton, R Eddie
- Affiliation:
- Royal (Dick) School of Veterinary Studies · United Kingdom
- Species:
- horse
Plain-English summary
A 7-year-old gelded Irish sports horse, weighing 650 kg, was put under anesthesia for two days in a row to clean out an infected joint in its front leg. During both procedures, the way the endotracheal tube (a tube used to help the horse breathe) was sealed with medical tape caused problems. Instead of allowing air to flow out properly, it created pressure that could have made breathing difficult, but this issue went unnoticed even though the veterinary team was monitoring the horse closely. Fortunately, the horse recovered well after both surgeries, but this situation could have been very dangerous for a horse with other health issues.
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.
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Search related cases →Original publication: https://pubmed.ncbi.nlm.nih.gov/23450862/