• Marcos Guilherme Cunha Cruvinel, Carlos Henrique Viana de Castro, and José Roberto de Rezende Costa.
• Departamento de Anestesiologia do Hospital Mater Dei, Belo Horizonte, MG. cruvinel@bis.com.br
• Rev Bras Anestesiol. 2003 Sep 1;53(5):640-5.

Background And ObjectivesAlthough rare, intraoperative awareness is a severe general anesthesia complication. Anesthesia machine malfunction is one of several causes for anesthetic complications, among them intraoperative awareness. This report aimed at showing a case where the volatile anesthetic monitor has detected machine malfunction which could have led to intraoperative awareness.Case ReportFemale patient, 38 years old, 55 kg, physical status ASA I, with right breast cancer, admitted for radical mastectomy and immediate myocutaneous flap reconstruction. Epidural puncture was performed at T8-T9 with a 17-gauge Tuohy epidural needle followed by the introduction of 18-gauge epidural catheter and administration of 0.2% ropivacaine. General anesthesia was then induced, followed by sevoflurane vaporization. Although other monitoring parameters have not detected relevant findings, the inhalational anesthetic monitor has not identified the presence of sevoflurane, thus allowing the diagnostic of vaporizer leakage.ConclusionsAlthough rare, intraoperative awareness is a severe complication which should be prevented. Routine and thorough anesthesia equipment inspection before its use may minimize failures. The inhalational anesthetics monitor is useful whenever inhaled anesthetics are being used and may early detect anesthesia machine failures as in this case report.

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