Loss Of Fresh Gas Flow Due To Malposition Of Vaporizer: An O
CASE REPORT
A 40 year old male patient, ASA Grade I, was posted for acromian decompression. The surgery was planned under general anaesthesia. The Blease Sirius Spacelabs anesthesia workstation (Blease Medical Equipment Limited, Washington, USA) passed the daily electronic system check and the circle breathing circuit was also manually checked using thumb occlusion test before the case. The BleaseDatum L Series halothane and sevoflurane vaporizers already mounted on the machine were each checked by performing leak pressure test .Standard monitors were attached and baseline parameters recorded. After premedication and preoxygenation, the patient was induced with 5mg/kg of thiopentone and 0.1mg/kg vecuronium; mask ventilation with 2.0% sevoflurane and N2O and O2 was performed. The patient was intubated, bilateral air entry checked; and switched over to volume controlled ventilation. The vital parameters remained stable. After intubation, it was decided to shift the patient on isoflurane. The technician replaced the already mounted upstream halothane vaporizer with the isoflurane vaporizer. The dial concentration was set at 2.0% aiming to maintain MAC 1.0. Soon after, there was a low minute volume alarm and the bellows were collapsing...

http://ispub.com/IJA/32/2/1613
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