Observations on use of wrong agent in an anesthesia agent vaporizer.
The creation of agent mixtures from the addition of the wrong agent to a vaporizer might pose a risk to the patient. Patient injury would be more likely if the anesthesia gas monitor displayed erroneous concentration values. Conventional inhalation agent monitors do not necessarily distinguish anesthetic agents. Some modern monitors have that ability but its clinical significance has not been determined. We wanted to simulate such an erroneous mixture in a laboratory setup. Six comparisons were made. Isoflurane, Enflurane, and Halothane vaporizers were first filled with the correct agent. They were run at 5 liters/minute fresh oxygen flow at a vaporizer dial setting of 5% until it reached the "refill" line. Then, one of two incorrect agents was added to the "full" line. Thereafter, the vaporizer continued at the same flow and the same dial setting until it was exhausted. Vaporizer output was recorded or calculated by using three methods of measurement: mass spectrometry, conventional infrared analysis (at 3.3 micrometer wave length), and piezoelectric crystal analysis. Additional calculations were used to estimate measurements that could not be made because of lack of available equipment. In a Halothane vaporizer: Enflurane added--not a significant problem; Isoflurane added--not a significant problem. In an Isoflurane vaporizer: Halothane added--not a significant problem; Enflurane added--not a significant problem. In an Enflurane vaporizer: Isoflurane added--not a significant problem; Halothane added--the sum of the delivered Halothane MAC and the delivered Enflurane MAC was twice the expected Enflurane MAC output from vaporizer, with conventional agent monitor reading which showed decreasing agent concentration. Patient injury could be more likely in this last case. In this last case and in all cases, piezoelectric crystal monitoring correctly displayed the sum of the two agent concentrations in volumes percent. Automatic agent identification can identify erroneous agents.
Block
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Department of Anesthesiology, The Ohio State University, Columbus, OH 43210, USA. feblock@life.uams.edu
Schulte
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D000769:Anesthesia, Inhalation / Q000009:adverse effects / Q000295:instrumentation*; D019162:Anesthetics, Combined / Q000008:administration & dosage*; D018685:Anesthetics, Inhalation / Q000008:administration & dosage*; D019300:Medical Errors
D019162:Anesthetics, Combined; D018685:Anesthetics, Inhalation