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Korean J Anesthesiol > Volume 52(5); 2007 > Article
Korean Journal of Anesthesiology 2007;52(5):578-581.
DOI: https://doi.org/10.4097/kjae.2007.52.5.578   
Awareness during General Anesthesia due to Vaporizer Malfunction: A case report.
Tai Kyung Seol, Jiyeon Sim, Hee Yeon Park, Wonsik Ahn
1Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Korea. aws@snu.ac.kr
2Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Abstract
We report a case of awakening during general anesthesia due to a vaporizer malfunction. The sevoflurane vaporizer had a hole through which approximately 20% of fresh gas escaped. The gas in the common gas outlet contained only 60% of the sevoflurane stated on the vaporizer setting. Moreover, the gas monitor module was out of order, and the heart rate and blood pressure were stable. As a result, we were unaware of the low sevoflurane concentration. The leakage through the hole could not be detected with the commonly used low-pressure system leak checking method. The implication of this case is that unexpected awakening can occur in patients with stable vital signs with an inhalation anesthesia. Therefore, more attention is needed to detect the level of patient awareness.
Key Words: awareness; preanesthesia machine check; sevoflurane; vaporizer malfunction
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