Disruption of water trap from leak of isoflurane during the vaporizer filling process in the Drager Apollo.

摘要

To the Editor:We write to inform your readers about our experience with the configuration of the Drager Apollo anesthesia machine (Drager Medical, Inc., Telford, PA). We have had several instances where end-tidal carbon dioxide readings were skewed or undetected by the gas analyzer after successful tracheal intubation. Upon inspection of the source of the problem, it was found that the water trap (positioned just below the isoflurane vaporizer; fig. 1) was severely cracked and disfigured (fig. 2). This compromise of the water trap led to the inability to accurately detect and monitor end-tidal carbon dioxide. Upon replacement of the water trap, accurate carbon dioxide monitoring was once again possible.It was discovered that during the filling process of the isoflurane vaporizer, a smal! amount of volatile anesthetic had dripped down on the water trap, leading to compromise of the integrity of the plastic outer shell of the trap and loss of the ability to accurately detect and monitor end-tidal carbon dioxide. These conditions were easily reproducible and always led to the same water trap disruption.