Case 52: A Loud “Pop” Intraoperatively and Now You Cannot Ventilate

Abstract

Today you are to anesthetize a 58-year-old man, ASA 2, for an anterior resection of a rectal cancer. He is otherwise healthy but is a big man of 150 kg and 5′8″. His airway is classified as 2. You bring him to the operating room and place him on a “ramp” for easier endotracheal intubation [1]. Noninvasive monitors are placed and you anesthetize him in a routine manner. He is easy to ventilate after being given succinylcholine. However, it is a grade 3 view. You place a gum elastic bougie blindly in the trachea and try initially a #9 endotracheal tube (ETT), but it will not go, neither will a #8 ETT. Eventually you settle for a #7 ETT. You make a mental note that his trachea must be big since you need to put a much larger than normal air volume into the ETT cuff to prevent a leak. With the airway now secured, the patient is put in a steep Trendelenburg position and the surgery starts. His arms are placed out at 90° from the body, and an upper body Bair Hugger blanket is placed. This is the variety of Bair Hugger that has sticky sides to the see-through face cover. The operation proceeds uneventfully, until a large “pop” is heard and the bellows of your Narkomed 2B, North American Drager, descend and stay down. You attempt manual ventilation by using the anesthesia machine’s collapsible breathing bag. This is unsuccessful. No air fills the bag, even though you use the oxygen flush control button and close off of the “pop of valve.” You ascertain that the anesthesia hoses are intact and in the correct position. You decide that the loud pop was the bursting of the ETT cuff. You immediately replace the “burst” ETT over a gum elastic bougie with a new one and blow up the cuff. However, there is no improvement. The oxygen saturation is now 76% and the surgeon has stopped working and is looking at you. You have no Ambu bag in the room and you call for one. While waiting, you mouth ventilate through the ETT. It is then that you see the problem. What is it?