AMSORB 1.0 KG CARTRIDGE

Description of Event or Problem

FIRST CASE IN MORNING AFTER INDUCTION OF GENERAL ANESTHESIA AND REDUCTION OF GAS FLOWS TO MAINTENANCE N2O 0.4 L/MIN+ O2 0.64 MIN; THE INSPIRED CO2 LEVEL WAS NOTED TO BE ELEVATED AND RISING, AS WELL AS THE END TIDAL CO2. RECHECK OF THE INSPIRATORY AND EXPIRATORY VALVES ON THE ANESTHESIA MACHINE REVEALED NO PROBLEM. THE CO2 ABSORBANT DID NOT APPEAR TO BE EXHAUSTED. INCREASING GAS FLOWS IMPROVED THE PROBLEM SOMEWHAT. AN ANESTHESIA TECH CALLED IN IMMEDIATELY KNEW WHAT THE PROBLEM WAS AS ANOTHER ANESTHESIOLIGST HAD EXPERIENCED THE SAME PROBLEM 6 DAYS AGO: THE "TRIAL" CO2 ABSORBANT CARTRIDGE LEAVES A GAP BETWEEN IT AND THE CANNISTER, ALLOWING EXPIRED GASES TO BYPASS THE ABSORBANT, RESULTING IN THE ELEVATED INSPIRED CO2. A CHANGE TO USUAL SYSTEM OF FILLING THE CANNISTER DIRECTLY WITH ABSORBANT ALLEVIATED THE PROBLEM IMMEDIATELY. OTHER THAN A TEMPORARY RISE IN BLOOD PRESSURE, THE PT REMAINED STABLE.