小兒胸椎手術末因姿勢改變而導致的突發性呼吸管完全阻塞之病例報告

Sudden Complete Obstruction of Breathing Circuit during Postural Change upon Completion of Thoracic Spinal Surgery in a Pediatric Patient

手術中替病人改變姿勢是一個麻醉醫師經常會遇到的情形。而在改變姿勢的過程中我們可能遇到各式各樣的併發症。這個病例是討論一個罕見的情形，一個小朋友在胸椎手術結束時翻過身後忽然發生呼吸完全阻塞的情形，原來是空氣細菌過濾器發生阻塞，可見空氣細菌過濾器的使用不是完全無害的。

Positioning patients during the perioperative period is a common event to anesthesiologists. A variety of complications may arise during this cumbrous moment. We describe a rare circumstance that we came across immediately after changing the posture of a pediatric patient at the end of thoracic spinal surgery. A total occlusion of the combined heat-moisture exchanger (HME) and bacterial/viral filter was responsible for breathing circuit obstruction. The use of the combined HME and bacterial/viral filter is not entirely riskless during general anesthesia.