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Canadian Journal of Anesthesia, Vol 37, 258-261, Copyright © 1990 by Canadian Anesthesiologists' Society

ARTICLES

Intraoperative awareness due to malfunction of a Siemens 900B ventilator

PD Slinger, WA Scott and AP Kliffer
Department of Anaesthesia, Montreal General Hospital, Quebec, Canada.

A case of intraoperative awareness during a thoracotomy is described. The patient's recall coincided with an intraoperative period during which a Siemens 900B ventilator and a Siemens 952 isoflurane vaporiser were used. Subsequent assessment of this equipment with an anaesthetic agent analyzer revealed that, at the ventilator settings which had been used, the delivered anaesthetic vapour concentration varied greatly from the vaporizer settings. This problem eventually was traced to a malfunctioning inlet control valve on the ventilator. This complication may have been prevented if the end-tidal anaesthetic concentration had been monitored intraoperatively.




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Copyright © 1990 by the Canadian Anesthesiologists' Society.