[Hypoxic gas mixture delivery due to a defective vaporiser manifold: case report, review of the literature and suggested emergency management algorithm].

A case of delivery of a hypoxic gas mixture to a patient during total intravenous anesthesia is described. A progressive fall in inspiratory oxygen concentration followed by a drop in oxygen saturation below 90 % occurred during the advanced stages of a hitherto uneventful general anesthesia of a female patient undergoing anterior cervical fusion surgery. A malfunctioning defective rubber seal of a vaporizer manifold was identified as the cause of the gas leak. The leak had not been detected during the preanesthesia leak test. The problem of hypoxic gas mixtures and uncommon leaks in modern anesthesia equipment is discussed. The importance of locating a leak in the high or low pressure circuits is explained. An algorithm for the management of an unexpected decrease of inspiratory oxygen concentration or any other manifestation of a gas leak along with a systematic approach to locating the source of a gas leak is presented.