Total Power Failure in a Desflurane Vaporizer Resulting in Discontinuation of Anesthetic Delivery

An unrecognized power failure in a desflurane vaporizer is possible with a concomitant alarm battery failure. Consequent discontinuation of desflurane delivery may go unrecognized and create the potential for intraoperative awareness and inadequate depth of anesthesia. Preventive measures could include assignment of an exclusive power outlet for the desflurane vaporizer, periodic replacement and testing of the alarm battery, vigilant monitoring and documentation of desflurane levels, and even potential re-design of the vaporizer alarm system.