It was reported that during a craniotomy and tumor removal/resection procedure the patient was in the prone position, toward the end of the procedure, the end-tidal co2 (etco2) was low and the patient was hard to ventilate.The surgeon noticed that the patient was experiencing intracranial pressure during the time that the patient was experiencing low end-tidal co2 (etco2).An additional anesthesia provider was called in to assist and replaced the entire anesthesia circuit, without a filter, after which the intracranial pressure was eliminated, the surgical site was closed and no additional medical intervention was required.The anesthesiologist stated that he evaluated the anesthesia circuit after the set was removed from the patient and he felt the filter was full of moisture.Due to the patient being in the prone position and the drapes covering the filter, the moisture in the anesthesia circuit filter was not noticed during the procedure.After the anesthesia circuit changed the surgeon was able to close the surgical site without further incident.There was no serious injury, follow-up medical care or medical intervention required.The filter was not returned for evaluation.A root cause cannot be determined.Due to the reported incident and in an abundance of caution, this medwatch is being filed.Incorrect mfr report number submitted on original report.
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