Leakage of sevoflurane from vaporizer detected by air monitoring system: a case report

Leakage of inhalational anesthetic gases is an important issue not only to staff health but awareness during general anesthesia. After inhalation of sevoflurane commenced, the audible and visible alarm of our custom-made air monitoring system was activated. The system measured 2–4 ppm of sevoflurane...

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Bibliographic Details
Published in:Journal of clinical monitoring and computing 2013-12, Vol.27 (6), p.629-631
Main Authors: Tanaka, Maiko, Yamaura, Ken, Higashi, Midoriko, Hoka, Sumio
Format: Article
Language:English
Subjects:
Administration, Inhalation
Air monitoring
Anesthesia
Anesthesia, General - instrumentation
Anesthesiology
Anesthesiology - instrumentation
Anesthetics
Anesthetics, Inhalation - administration & dosage
Clinical Alarms
Critical Care Medicine
Environmental Monitoring - instrumentation
Equipment Failure
Gases
Health Sciences
Humans
Inhalation
Intensive
Leakage
Male
Medicine
Medicine & Public Health
Methyl Ethers - administration & dosage
Middle Aged
Monitoring
Nebulizers and Vaporizers
Occupational Exposure
Operating Rooms
Original Research
Statistics for Life Sciences
Stomach Neoplasms - surgery
Surgery
Vaporizers
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Summary:Leakage of inhalational anesthetic gases is an important issue not only to staff health but awareness during general anesthesia. After inhalation of sevoflurane commenced, the audible and visible alarm of our custom-made air monitoring system was activated. The system measured 2–4 ppm of sevoflurane. A thorough search failed to identify the source of the leak. After changing inhalational anesthesia to intravenous anesthesia, the concentration of sevoflurane decreased immediately to zero. The filling level on the vaporizer decreased faster than usual. A thorough check of the vaporizer after surgery identified a worn down seal in the filling device of the vaporizer.
ISSN:1387-1307
1573-2614
DOI:10.1007/s10877-013-9479-9