Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Case Report

Oxygen delivery failure due to improper installation of carbon dioxide absorbent canister: a case report

Sher-Lu Pai, Christopher B. Robards, Kevin T. Riutort, Klaus D. Torp

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The CLIC system in the Dräger Apollo anesthesia workstation allows a successful pre-use machine checkout without the presence of a carbon dioxide absorbent canister. It also allows the canister to be changed without interrupting controlled ventilation. However, this canister can be easily installed improperly with the CLIC adapter. We report a case in which a patient could not be ventilated by mask after the induction of general anesthesia, resulting in oxygen desaturation before successful ventilation was achieved with a bag valve mask. This case illustrates the importance of a leak test after components of the breathing circuit are changed.


Anesthesiology,  Carbon dioxide,  Positive pressure respiration,  Soda lime,  Ventilators, mechanical


1 Drager Just “CLIC” it! (2015) Available at: Accessed 2019 Apr 22

2 Drager Advanced Anesthesia Solutions: Drager Apollo Anesthesia Workstation (2017) Available at: Accessed 2019 Apr 22

3 SA Ianchulev, ME Comunale To do or not to do a preinduction check-up of the anesthesia machine Anesth Analg, 101 (2005), pp. 774-776

4 American Society of Anesthesiologists ASA Recommendations for Pre Anesthesia Checkout Available at: Published 2019. Accessed Apr 22, 2019 (2008)

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Braz J Anesthesiol

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