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
Highlights
Intra operative awareness is an important complication during general anaesthesia, incidence ranging from 0.2 to 0.4%
On thorough examination of the anaesthesia machine, it was found that the floats in both O2 and N2O rotameters were moving up even when both the N2O cylinders were closed and one O2 cylinder was kept open. (Figure 1) On opening the oxygen failure safety valve by the mechanic, it was found that the diaphragm was ruptured
A defective fail-safe gas-loaded regulator resulted in oxygen flow through the N2O flowmeter.[3]
Summary
Introduction Intra operative awareness is an important complication during general anaesthesia, incidence ranging from 0.2 to 0.4%.1 Significant psychological sequelae may develop after such an episode. We present a case of intra operative awareness due to malfunctioning of anaesthesia machine. Case Report A 15 year old female patient weighing 42kg, was posted for implant removal from left forearm.
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
