Alerta De Seguridad para Carbon Dioxide Absorbers in Anesthesia (1) Unit of Carbon Dioxide Absorbents (Anesthesia Unit Carbon Dioxide Absorbents); (2) Anesthesia Unit Carbon Dioxide Absorbers; (3) Circulated Anesthesia System.

Safety alert

224

2000-12-15

Brazil

ANVISA

http://www.anvisa.gov.br/sistec/alerta/consultaralerta.asp

There are references to various incidents of patient exposure to carbon monoxide (co) and an incident of injury to the patient has been reported. ecri continues to receive calls about this topic and has updated the original article. ecri states that co is produced when halogenated anesthetic agents come into contact with commonly used co 2 absorbers that are extremely dry due to hospital gas flow during prolonged periods of inactivity of anesthesia equipment. based on investigations, ecri concluded that hazardous levels of co were produced within systems under conditions which included the presence of excessively dry co 2 absorbers and were used to provide halogenated anesthetic agents during the first day surgery, fairs ecri states that similar incidents are reported in the medical literature, with co exposure time being a common feature.

ECRI makes the following recommendations: (1) Inform the anesthesiologists and other staff involved about the problem and the ECRI report. (2) Make sure all hospital gases have been closed when the anesthesia system is not to be used immediately for another procedure. At the end of the day, make sure all hospital gases are closed in all anesthesia systems. (3) Before using the anesthesia system in the first case of the day, make a pre-use check, check for any hospital gas flow. If so, replace the absorber in both filters before using the system. Also, identify and address the cause of the hospital gas flow. For more information, contact your local representative.