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Mask Induction Despite Circuit Obstruction: An Unrecognized Hazard of Relying on Automated Machine Check Technology

Yang, Kamie K. MD; Lewis, Ian H. MBBS, MRCP, FRCA

doi: 10.1213/XAA.0000000000000026
Case Reports: Case Report

Various equipment malfunctions of anesthesia gas delivery systems have been previously reported. Our profession increasingly uses technology as a means to prevent these errors. We report a case of a near-total anesthesia circuit obstruction that went undetected before the induction of anesthesia despite the use of automated machine check technology. This case highlights that automated machine check modules can fail to detect severe equipment failure and demonstrates how, even in this era of expanding technology, manual checks still remain essential components of safe care.

From the Department of Pediatric Anesthesia, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan.

Accepted for publication January 15, 2014.

Funding: This work was unfunded.

The authors declare no conflicts of interest.

Address correspondence to Kamie Yang, MD, University of Michigan, Department of Pediatric Anesthesiology, 4–911 C.S MOTT Children’s Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI 48109-4245. Address e-mail to

© 2014 International Anesthesia Research Society