Incidents with potential for awareness, where patients were followed up (n = 34)
| Details | Cases | Intraoperative presentation |
|---|---|---|
| Incidents related to volatile agents and vaporisers | ||
| Vaporiser off. Accidental | 4 | Tachycardia, hypertension, lacrimation, movement |
| Vaporiser off. Deliberate | 3 | Movement |
| Malpositioned vaporiser | 3 | Hypertension, circuit leak, patient movement |
| Empty vaporiser | 1 | Lacrimation |
| Cracked vaporiser mount | 1 | Circuit leak |
| Faulty vaporiser | 1 | Patient movement |
| Patient difficult to ventilate | 1 | Circuit leak |
| Incidents related to ventilators | ||
| Leak, oxygen entrainment | 3 | Patient movement, oxygen analyser |
| Ventilator not turned on | 1 | Suspicion |
| Incidents related to circuit leaks | ||
| Common gas outlet problem | 3 | Circuit leak, oxygen analyser |
| Leak elsewhere | 1 | Circuit leak |
| Incidents related to oxygen flush mechanism | ||
| Oxygen flush jammed on | 2 | Oxygen analyser, direct observation |
| Incident related to transfer of patient from induction room to theatre | ||
| Delay, without anaesthesia | 1 | Patient movement |
| Incidents related to total intravenous anaesthesia | ||
| Failure to deliver anaesthetic agent | 2 | Hypertension, patient movement |
| Miscellaneous incidents | ||
| N2O delivery failure | 5 | Tachycardia, hypertension |
| Difficult intubation | 1 | Suspicion |
| Difficult tracheostomy | 1 | Suspicion |