Inadvertent change of volatile anesthetics in anesthesia machines.
Anesth Analg 1982 Jan; 61(1):53-55
An attempt was made to determine how frequently anesthesia vaporizers were filled with the wrong agent in a large institution with an anesthesia staff of about 120 of which 40 percent were students. Also this study endeavored to determine whether a particular type of vaporizer was more apt to be incorrectly filled and what the potential hazards were to the patients. No erroneous fillings of the kettle type Ohio and Foregger machines with halothane (151677) and enflurane (13838169) were documented. The Drager Vapor-19 vaporizers for enflurane and halothane were of the same external configuration and this resulted in five documented instances of filling with the wrong agent which resulted in the delivery of either a higher or lower than expected anesthetic concentration as well as the delivery of an agent not chosen or desired by the anesthesiologist. It is suggested that a keyed system would avoid this problem, but such systems have not been widely accepted in practice. In the absence of such a system, clear color coding is recommended. Testing of the vaporizers for retained volumes of gas after they had been supposedly cleared indicated that prolonged flushing with oxygen is required before switching the vaporizer from one agent to another. Several of the tested vaporizers were shown to contain a mixture of the two anesthetic gases when only one was expected to be present.
NIOSH-Publication; NIOSH-Grant; Grants-other; Anesthesiology; Hospital-equipment; Equipment-design
Anesthesiology Box 3094 Duke University Durham, N C 27710
Other Occupational Concerns; Grants-other
Anesthesia and Analgesia
Duke University, Durham, North Carolina