麻醉病患安全：呼吸管路系統

Patient Safety during Anesthesia: the Breathing Circuit System

Two case reports published in this issue touch on the problems relative to malfunctions of the unidirectional valve and heat-moisture exchanger (HME) in the breathing circuit of the anesthesia machine during anesthesia. The first report describes a patient who developed hypercarpnia during induction of anesthesia as a result of rupture of the inspiratory unidirectional valve in the breathing circuit. The other concerns a complete obstruction ofbreathing circuit after changing the posture of a pediatric patient at the end of thoracic spinal surgery in consequence of a total obstruction of the HME.