Sevoflurane Contamination: Water Accumulation in Sevoflurane Vaporizers Can Allow Bacterial Growth in the Vaporizer.

Sevoflurane vaporizers (GE Tec 7) were difficult to fill with "slow flow" and a need to "burp." Evaluation of the bottle of sevoflurane (AbbVie Ultane) demonstrated a contaminant. Four of the facilities' 13 sevoflurane vaporizers had the contaminant. Unopened sevoflurane bottles did not have evidence of contamination. The contaminant was found to be water at pH 6.0 growing Staphylococcus epidermidis. Gas chromatography revealed the production of multiple metabolites of sevoflurane, including primarily urea and 1,3,5-triazine-2,4,6(1H,3H,5H)-trione (83% and 9.6% of volatiles) in addition to multiple other organic molecules. Sevoflurane contains water that can accumulate in vaporizers allowing bacterial growth.