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Vaporizer Interlock Systems Can Fail

Interlock systems have been designed to prevent the anesthesia provider from turning on more than one vaporizer at a time. Prior to interlock systems, the patient could be given two anesthetic agents at the same time, causing rapid, severe hypotension and sometimes death. Interlock systems link two or three vaporizers to the fresh gas flow pipeline of the anesthesia machine. A mechanical device allows the fresh gas flow to enter only the vaporizer turned on by the anesthesia provider.

A survey of the MAUDE (Manufacturer and User Facility Device Experience Database) of the Center for Devices and Radiological Health was done for interlock system malfunction reports for the years 2002 to Jan, ...

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