An unexpected Penlon Sigma Elite Vaporizer leak.

THE Penlon Sigma Elite vaporizer (Penlon Ltd., Radley Road, Abingdon, UK) has been widely distributed throughout the United States to meet the consumer demand for delivery of sevoflurane. We present a case describing a Penlon Sigma Elite Vaporizer leak that was not detected using the 1993 Food and Drug Administration (FDA) Anesthesia Apparatus Checkout Recommendations' for anesthesia gas delivery machines. To our knowledge, this is the first case report describing a potential problem with the Penlon Sigma Elite Vaporizer when used on an Ohmeda Modulus II anesthesia machine (Madison, WI).