[Vaporizer malfunction--a cause of high concentration halothane vapor delivery]

Excessively high concentration of halothane vapor was delivered to the inspiratory gas mixture due to the vaporizer malfunction (Fluotec 4). After disassembling the vaporizer, corrosion was observed on the internal components. This was considered as the reason for the high halothane output. Proper regular check up, use of appropriate monitoring devices, and a preuse equipment checklist may help improve the quality of patient care and decrease the morbidity and mortality associated with anesthesia equipment. Anesthesia machines should receive regular check up at least once a year and anesthesia providers should routinely use an equipment checklist. It is also important to realize that anesthesiologist's senses of sight, hearing, touch, and smell are exceedingly reliable monitors for decreasing the incidence of anesthesia mishaps.