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

D’Mello, Ajay J. MD*,†; Raman, Vidya T. MD*,†; Tobias, Joseph D. MD*,†

doi: 10.1213/XAA.0000000000001045
Case Reports

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.

From the *Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio

Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.

Accepted for publication April 30, 2019.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Ajay J. D’Mello, MD, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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