Unexpected Anesthetic Circuit Leak Attributed to Improper Use of a Tube Holder: A Case Report

Leaks involving the anesthesia circuit can cause significant complications including hypoxia and hypoventilation. We present a case of a circuit leak caused by damage to the corrugated tubing attributed to improper use of the tube holder. A 58-year-old male was scheduled for resection of a palatal tumor under an intubated general anesthetic. After successful nasotracheal intubation, the anesthesiologist inserted the corrugated tubing of the anesthetic circuit into the tube holder. A leaking sound was heard and a tear in the corrugated tubing was promptly discovered. The corrugated tubing of the anesthetic circuit presumably tore because it was inserted into the groove of the tube holder at an inappropriate angle with excessive force. Anesthesiologists should be aware of potential leaks if the anesthesia circuit is damaged, which may be caused by improper use of tube holders.