“Think beyond the circuit: Flow sensor malfunction as a cause of Anaesthesia system leak

Abstract

Leaks during anaesthesia can create many life-threatening situations in Operation theatre. We would like to present one case scenario where we started OT only after Preuse checklist completion but we encountered massive leak in anaesthesia system in last case of the day while all other cases went uneventful. Despite all our efforts, we couldn’t find source of leak. Then we called workstation technician, who disassembled workstation and found broken flow sensor tubing in compact breathing system. As we were not aware about this, we couldn’t find this source of leak. In our opinion, Anaesthetist should be familiar about this hidden but accessible part of anaesthesia workstation to avoid oneself in landing these conditions and for better patient care to decrease chances of hypoventilation, hypoxia and other situations which can arise because of leak in anaesthesia system.