Interruption in the supply of breathing gas during general anesthesia due to malposition of the vaporizer: A case report / 대한마취과학회지

We report a case of interruption in the supply of breathing gas during general anesthesia caused by malposition of the Drager Vapor 2000(R) vaporizer, which was accidentally tilted and lifted off the Selectatec manifold of the anesthesia machine. Because the patient was an 1-month-old infant, we couldn't check if he had experienced awareness with recall. We emphasize the importance of checking the anesthetic vaporizer after mounting it on the back bar of the anesthesia machine.

An Unexpected Vapor Leakage from Unlocked Vaporizer (Penlon Sigma Delta Anesthetic Vaporizer): A case report / 대한마취과학회지

We present a case of an anesthetic gas leak through the valve of the Selectatec back bar during a surgical procedure. The Selectatec Vaporizing System is a quick-change system consisting of anesthetic vaporizers of the 'Tec models' of the Ohmeda machine that are seated on a compatibility manifold block located on the back bar of the anesthetic machine. In order to prevent a leak and a failure of vapor delivery, the "Tec models series" can only be turned 'on' when the locking lever is turned to the 'lock' position. However in this case, the control knob was rotated despite the back bar locking mechanism not being engaged, and a gas leak developed through the unlocked valves in Selectatec back bar. The Penlon Sigma Delta Anesthetic Vaporizer (sevoflurane) in a Datex-Ohmeda Aestiva/5 anesthesia machine can be turned 'on' when the locking lever is maintained at the 'unlock' position.