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Isoflurane damage to a Draeger Primus water trap

2006; Lippincott Williams & Wilkins; Volume: 23; Issue: 6 Linguagem: Inglês

10.1017/s0265021506240754

1365-2346

C. S. Ábrahám, Sagar Deshpande,

Airway Management and Intubation Techniques

EDITOR: We have recently had a critical incident related to equipment malfunction which we feel would be valuable to bring to the attention of others. We induced a 33-yr-old ASA Grade II female in the anaesthetic room for a laparoscopic cholecystectomy. Once we had transferred the patient to theatre and connected the monitors, we noticed unusually low end-tidal values for oxygen, nitrous oxide, isoflurane and carbon dioxide, despite normal inspiratory values. The condition of the patient and the connections was assessed and found to be satisfactory. We then noticed the water trap was cracked (Fig. 1). Replacing the water trap led to the return of normal values and the case continued uneventfully. We feel the damage to the water trap had occurred during spillage of isoflurane whilst filling the Vapor 2000 vaporizer, causing it to crack and leak.Figure 1.: Cracked water trap.We received a report from the manufacturer which stated that a damaged water trap will be detected during the Primus Power-On Self Test. To prevent 'dripping' of anaesthetic agent onto the water trap they recommended following certain points during the filling process. First, the filling adaptor should be tightly locked at the agent's bottle (and if old filling adaptor's without check valves are being used, they should be changed to the new version, available since 1998, to speed up the filling process). Second, the filling adaptor should only be fastened hand tight, without applying too much force, to avoid twisted or damaged seals inside the vaporizer's filling system. If the filler plate seals show signs of wear, they should be replaced with new seals. Finally, only original Draeger filling adaptors should be used, to prevent damage to the seal inside the vaporizer's filling system, resulting from the use of unapproved filling adaptors. If the above points are followed, there is no need to remove the vaporizers from the Primus during the filling process, as the keyed filling system is designed to be leak proof. To prevent gas leakage resulting from the above procedure, a leak test should be performed after a change or filling a vaporizer. Similar problems have been reported by Vemmer and colleagues [1], and at that time the manufacturer recommended removing the vaporizer for refilling. However, the advice we have received which is more recent states this is not necessary, as does the Association of Anaesthetists of Great Britain and Ireland [2]. We have reported this incident to the Medicines and Healthcare products Regulatory Agency in the UK and have distributed this information amongst our department to increase awareness of this potential problem. C. Abraham S. K. Deshpande Department of Anaesthetics, South Tyneside District Hospital, Tyne and Wear, UK