Contamination of piped medical gas supply with water

Abstract

The failure of anaesthetic equipment as a result of maintenance is extremely rare. The ingress of water into the flowmeters of an anaesthetic machine from the piped medical air supply is reported and is possibly unique. The piped medical air supply was open to the atmosphere during maintenance. Water condensed in the gas pipeline and this was not noticed during subsequent testing. Water was seen leaking from the orthopaedic air tools used for surgery but was assumed to be from the autoclaving process. Later the same day, when medical air from the piped source was used as part of the gas mixture for a general anaesthetic, water was seen filling the barrel of the flowmeter air control valve. This could have had far-reaching and dangerous consequences for the patient, which were fortunately averted.