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Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence

Authors:

Debasish Bhar ,

IN
About Debasish
Assistant Professor, Department of Anaesthesiology,Midnapore Medical College, Paschim Midnapore, West Bengal,
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Sudeshna Bhar Kundu,

IN
About Sudeshna
Assistant Professor, Department of Anaesthesiology, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal,
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Partha Sarathi Halder

IN
About Partha
Assistant Professor, Department of Anaesthesiology,Midnapore Medical College, Paschim Midnapore, West Bengal,
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Abstract

A 15 year old female patient of ASA class I was posted for implant removal from left forearm under general anaesthesia. Intraoperative period was uneventful. In the immediate postoperative period, she became restless which subsided after administration of haloperidol and promethazine intramuscularly. On interview, she complained of intraoperative awareness. Thorough checking of the anaesthesia machine revealed that the floats in both oxygen and nitrous oxide rotameters were moving up even when both nitrous oxide cylinders were closed and one oxygen cylinder was kept open. The diaphragm of oxygen failure safety valve was found to be ruptured which allowed oxygen to flow through nitrous oxide flow meter. Preoperative checking of the anaesthesia machine could not identify these abnormalities. Thus, meticulous checking of anaesthesia machine including the oxygen failure safety valve, intraoperative monitoring of depth of anaesthesia, use of oxygen and end-tidal anesthetic gas analyzer may be helpful to prevent such an incident.

DOI: http://dx.doi.org/10.4038/slja.v21i2.5235

DOI: http://doi.org/10.4038/slja.v21i2.5235
How to Cite: Bhar, D., Bhar Kundu, S. & Halder, P.S., (2013). Intra operative awareness due to malfunctioning of anaesthesia machine - A rare incidence. Sri Lankan Journal of Anaesthesiology. 21(2), pp.76–78. DOI: http://doi.org/10.4038/slja.v21i2.5235
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Published on 16 Jun 2013.
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