Anaes Cases · Vaporisers
Isoflurane poured into a sevoflurane vaporiser
The short case — the agent-specific design defeated: the wrong agent in a vaporiser calibrated for another agent produces an unpredictable (often dangerously high) output concentration because of the different SVP and splitting ratio.
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ANZCAFRCAABAEDAIC
Prompt
At the start of a list, a technician has filled the sevoflurane vaporiser from a bottle labelled isoflurane. The keyed filler was defeated with an adapter. Assess the risk and the action.
Presentation
At the start of the morning list, the sevoflurane vaporiser on the back bar is found to have been filled from a bottle labelled isoflurane. The keyed (agent-specific) filler was defeated with a universal adapter. The vaporiser dial is labelled sevoflurane and is calibrated for sevoflurane. The first patient has not yet been induced.
References1ShowHide
- [2]Tiviraj S, et al. Development of An Assessment Test for An Anesthetic Machine. J Med Assoc Thai, 2016.PMID 27501622