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KMID : 0356920090560060657
Korean Journal of Anesthesiology
2009 Volume.56 No. 6 p.657 ~ p.693
Awareness during general anesthesia due to the unlock position of the vaporizer - A report on two cases -
Kim Kyoung-Hun

Cho Sang-Yun
Kim Kyu-Nam
Shim Jae-Hang
Jeon Woo-Jae
Yeom Jong-Hoon
Shin Woo-Jong
Abstract
Awareness with recall after general anesthesia is a relatively infrequent occurrence and this awareness is often associated with significant adverse psychological sequelae, including posttraumatic stress disorder. The occurrence of awareness is often the consequence of the light anesthetic techniques with using minor anesthetic agents. Because the locking lever of the Penlon Sigma Delta Anesthetic vaporizer (sevoflurane) was at the unlock position, disconnection happened between the anesthetic machine and the vaporizer (the Selectatec? vaporizing system). In our two cases, the inhalation agents were not supplied and awareness with recall was identified after surgery. We recommend to check the concentration of the inhalation agents by monitoring the concentration of using endtidal inhalation agents and to measure the hypnotic level of anesthesia via the bispectral index (BIS) and the auditory evoked potential (AEP).
KEYWORD
Awareness, Disconnection, Vaporizer
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