잠금장치가 안 된 Penlon Sigma Delta Anesthetic Vaporizer (Sevoflurane)에서의 가스누출

We present a case of an anesthetic gas leak through the valve of the Selectatec back bar during a surgical procedure. The Selectatec Vaporizing System is a quick-change system consisting of anesthetic vaporizers of the ``Tec models`` of the Ohmeda machine that are seated on a compatibility manifold block located on the back bar of the anesthetic machine. In order to prevent a leak and a failure of vapor delivery, the "Tec models series" can only be turned ``on`` when the locking lever is turned to the ``lock`` position. However in this case, the control knob was rotated despite the back bar locking mechanism not being engaged, and a gas leak developed through the unlocked valves in Selectatec back bar. The Penlon Sigma Delta Anesthetic Vaporizer (sevoflurane) in a Datex-Ohmeda Aestiva/5 anesthesia machine can be turned ``on`` when the locking lever is maintained at the ``unlock`` position. (Korean J Anesthesiol 2006; 51: 230~2)