PERFUSION REPORTS

REPORT

013

DATE

TITLE

Isoflurane Vaporiser Seal Leak Due To Malposition

DETAILS OF INCIDENT

An Isoflurane vaporiser was full and on a hanger suspended from a vertical pole. The vaporiser was allowed to rest on the base of the pump console. This caused the vaporiser seals to leak causing a reduction of flow. An unusually high flow rate was necessary to maintain normal blood gases to the patient. Once the vaporiser was repositioned without touching the base no further problems were encountered.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

Vaporisers should not be allowed to touch the base of the console if suspended from a hanger pole due to the possibilities of gas leakages from the seals. This has been reported in the anaesthetic journals.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

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Detached bullet tip of sump-updated response Sep 2022

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