Korean Journal of Anesthesiology

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Case Report
Korean J Anesthesiol. 2009;56(6):693-697.
DOI: https://doi.org/10.4097/kjae.2009.56.6.693
Awareness during general anesthesia due to the unlock position of the vaporizer : A report on two cases.
Kyoung Hun Kim, Sang Yun Cho, Kyu Nam Kim, Jae Hang Shim, Woo Jae Jeon, Jong Hoon Yeom, Woo Jong Shin
Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Guri Hospital, Guri, Korea. chosy@hanyang.ac.kr
Abstract
Awareness with recall after general anesthesia is a relatively infrequent occurrence and this awareness is often associated with significant adverse psychological sequelae, including posttraumatic stress disorder. The occurrence of awareness is often the consequence of the light anesthetic techniques with using minor anesthetic agents. Because the locking lever of the Penlon Sigma Delta Anesthetic vaporizer (sevoflurane) was at the unlock position, disconnection happened between the anesthetic machine and the vaporizer (the Selectatec(R) vaporizing system). In our two cases, the inhalation agents were not supplied and awareness with recall was identified after surgery. We recommend to check the concentration of the inhalation agents by monitoring the concentration of using endtidal inhalation agents and to measure the hypnotic level of anesthesia via the bispectral index (BIS) and the auditory evoked potential (AEP).

Keywords :Awareness;Disconnection;Vaporizer

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