A surprising twist: an unusual failure of a keyed filling device specific for a volatile inhaled anesthetic.

Abstract

We describe two cases in which keyed filling devices for sevoflurane were inadvertently screwed onto isoflurane bottles. The mishaps were possible because the collars on sevoflurane and isoflurane bottles are mirror images of each other. The particular keyed filling device was designed with a flexible outer sleeve and could be screwed onto the wrong bottle while slightly gouging its soft plastic collar. The keyed filling adapters for sevoflurane and isoflurane could each be manipulated to fit the other's bottle. A manufacturer (Southmedic, Inc., Barrie, Canada) has modified their keyed filling adapters to prevent this unusual circumstance from recurring.