Inadvertent Tracheal Clamping During Shunt Ligation: The Vital Role of Respiratory Mechanics Monitoring: A Case Report

This case describes a sudden drop in end-tidal carbon dioxide after modified Blalock-Taussig shunt clamping in a 3-year-old baby boy with a tetralogy of Fallot undergoing intracardiac repair. It was accompanied by abnormal ventilatory parameters, raising suspicion of airway obstruction. Intraoperative assessment revealed accidental tracheal clamping instead of the shunt, which was corrected promptly. The case highlights the importance of continuous respiratory monitoring—including capnography, peak airway pressures, tidal volume, and pressure-volume loops—to differentiate between expected physiological responses and potentially life-threatening complications such as tracheal occlusion during cardiac surgery.