Examining the anesthesia machine prior to administering general anesthesia is an essential procedure. Newer electronic machines have a computerized safety check that allows for the detection of most defects prior to use. However, breaks in the breathing circuit that go undetected during a leak test can lead to unexpected ventilation failures. In cases of ventilation failure during anesthesia, the respiratory circuit is usually replaced. Such requirements can expose the patient to life-threatening hypoxemia during the exchange of the circuit system. This report presents a case in which a leak test did not detect a defect in the breathing circuit, highlighting the need for vigilance and for additional safety measures in anesthesia practice.
