Unexpected anesthetic leakage from a damaged O-ring on the Selectatec back bar: A case report.
10.17085/apm.2017.12.2.183
- Author:
Young Uk KIM
1
;
Jimi OH
;
Chan Hye PARK
;
Byung Moon CHOI
;
Dong Min JANG
;
Ji Yeon BANG
Author Information
1. Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University of Korea College of Medicine, Incheon, Korea.
- Publication Type:Case Report
- Keywords:
Intraoperative awareness;
Vaporizer;
Ventilator
- MeSH:
Friction;
Intraoperative Awareness;
Nebulizers and Vaporizers;
Ventilators, Mechanical
- From:Anesthesia and Pain Medicine
2017;12(2):183-186
- CountryRepublic of Korea
- Language:English
-
Abstract:
The Selectatec mounting system was devised to provide easy and quick on-site fitting of various vaporizers for the anesthetic machine. However, a quick changing system for the vaporizer can also damage the O-ring due to friction between the vaporizer and the Selectatec back bar. We herein report a case of an unexpected anesthetic gas leakage from a damaged O-ring on the Selectatec back bar, which resulted from exchanging the vaporizers between two operations. In cases using the Datex Ohmeda machine, it is not easy to detect leakages from the vaporizers because of the location of the check valve near to the fresh gas outlet. This complicates the use of the positive pressure leakage test to detect a low pressure system leakage on the Selectatec back bar. We recommend the preanesthetic negative pressure or low-flow leakage test to detect a low pressure leakage when exchanging vaporizers on the Selectatec system.
