Massive Inhalation of Desflurane due to Vaporizer Dysfunction

Patient Injuries from Anesthesia Gas Delivery Equipment

“…15 Improved vigilance and monitoring of endtidal anesthetic agent concentrations can readily detect most vaporizer problems. 16,17 The current ASA Standards for Basic Anesthesia Monitoring ‡ ‡ do not require monitoring of anesthetic agents (or nitrous oxide) in the inspired gas mixture. However, as more practitioners are now using agent analysis, it may become a de facto standard of care.…”

Occupational exposure to methoxyflurane administered for procedural sedation: an observational study of 40 exposures

“…Whilst a nephrotoxic threshold for acute exposure to methoxyflurane was calculated by Cousins and Mazze, 3 until recently there were no data on a safe level for chronic lowlevel exposure in staff. In 2016, Frangos and colleagues 4 derived a maximum exposure limit for methoxyflurane of 15 ppm as an 8-h time weighted average (TWA), using the benchmark dose method to extrapolate a safe chronic exposure limit from acute toxicity data.…”

“…For volatile anaesthetic agents in general, international exposure standards vary as no specific safe threshold has been derived for reproductive toxicity. Montpellier, France, 2 Paris, France, 3 Strasbourg, France, 4 Bordeaux, France and 5 Reims, France *Corresponding author E-mail: paul-michel.mertes@chru-strasbourg.fr EditordAllergy to neuromuscular blocking agents (NMBA) is the leading cause of perioperative anaphylaxis in France. In the last GERAP survey (Groupe d'Etude des R eactions Anaphylactiques Peroperatoires), proved NMBA allergy accounted for 60.6% of the immediate hypersensitivity reactions in the perioperative setting (302 patients explored between 2011 and 2012).…”

Over-delivery of desflurane via Aisys Carestation Aladin2 Cassette™ vaporiser

“…This is definitely a cause for concern, as sudden transient cardiac arrest has been reported because of a very high concentration of desflurane delivered inadvertently. 3 This case has been brought up to the regional GE Healthcare product specialist. We investigated the incident immediately after the patient left the operating theatre.…”