Intensive Care Unit mishap during nebulization.

Abstract

Sir, Sixty-year-old lady, operated for emergency coronary artery bypass grafting surgery, was tracheostomized due to prolonged need for ventilatory support. As per the protocol, the patient was to be given nebulization every 6 hours by attending nurse. On one occasion, nebulizer apparatus was attached to the catheter mount, which was attached to the tracheostomy, and the other end of nebulizer apparatus was attached to the breathing circuit connected to the ventilator. Suddenly after 15 s ventilator started giving the alarm of inadequate delivery of tidal volume. Nurse checked for any disconnection or leakage in the circuit. Saturation of the patient began to come down from 99% to 85% and patient's heart rate came down from 90 to 50/min. Immediately Intensive Care Unit (ICU) doctor was called upon, and considering nonexpansion of the chest, breathing circuit along with nebulizer kit was removed and attending doctor ventilated the patient with Ambu bag with 100% oxygen. Injection mephentermine 5 mg intravenous was given rapidly. After few seconds, saturation increased to 99% with stable hemodynamics. After the episode, reason for the event was searched. Ventilator machine with breathing circuit was checked for any leakage with test lung. It was functioning optimally. Tracheostomy tube blockage or misplacement was ruled out as the patient could be ventilated with Ambu bag very smoothly. At last nebulizer kit was checked and it was observed that one end of nebulizer apparatus was blocked with transparent cap [Figure 1]. Even with the cap, nebulizer apparatus can be fitted very easily with catheter mount connected to the tracheostomy tube. Patient could not be ventilated due to capped (blocked) nebulizer leading to the event. Figure 1 Nebulizer apparatus with transparent cap Prospective, observational ICU study has reported 7.04% of airway accidents leading to hypoventilation and hypoxia.[1] These airway accidents mainly included blocked tube, unplanned extubation (self and accidental), endobronchial intubation, kinked tube, and leaking cuff. ICU mishap due to defective nebulizer as in the present case has not been described in the literature. Saline nebulization is commonly used for adequate humidification and prevention of encrustation of tracheal tubes.[1,2] Manufacturer of nebulizer kit should pay the attention to the production of such nebulizer apparatus with a transparent cap that can easily go unnoticed and fit into the breathing circuit easily with cap. Error in checking nebulizer kit can lead to fatal ICU accident.