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 Table of Contents    
LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 5  |  Page : 416-417  

A curious case of intravenous cannula


1 Department of Anaesthesiology, B.P.S. G.M.C. for Women, Khanpur Kalan, Sonipat, Haryana, India
2 Department of Community Medicine, Dr. S.N. Medical College, Jodhpur, Rajasthan, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. Prateek
H.No. 888a, Ward 27, Azad Nagar, Thanesar, Kurukshetra - 136 119, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_837_18

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How to cite this article:
Prateek, Bansal P, Jain P, Tak H. A curious case of intravenous cannula. Indian J Anaesth 2019;63:416-7

How to cite this URL:
Prateek, Bansal P, Jain P, Tak H. A curious case of intravenous cannula. Indian J Anaesth [serial online] 2019 [cited 2019 Jul 19];63:416-7. Available from: http://www.ijaweb.org/text.asp?2019/63/5/416/258071



Sir,

We discuss a case where a small manufacturing defect may have lead to significant blood loss in a minor surgery, but catastrophe was averted.

In the case being discussed, the reverse flow of blood was seen emanating from the injection port of the intravenous (IV) cannula [Figure 1]. Flow reversal has been observed from the Luer Lock of IV cannula, but not from the injection port. First, measurement of noninvasive blood pressure monitoring in the same limb was excluded, followed by exclusion of arterial cannulation and arteriovenous fistula, with the use of ultrasonography and arterial blood gas analysis. This lead us to suspect that that there may be a manufacturing defect in the IV cannula.[1],[2] It was thought that the valve in place has been displaced and rendered ineffective while pushing drug through the injection port. To enable the maintenance of IV hydration intraoperatively, it was thought to be prudent to remove the present IV cannula, after cannulating another vein. However on connecting the IV infusion set to the second cannula, blood again started flowing from the injection port. Now a new IV infusion set was used to connect the IV maintenance fluid to the cannula, so as to exclude a defective IV set. On careful examination, it was observed that the connector of the first IV infusion set had been joined in a reverse manner at the end of the IV infusion set [Figure 2]. This lead to increased length of the connector, which when inserted into the IV cannula displaced the valve inside the injection port, leading to loss of IV fluid and blood. None of the other IV infusion sets was found to be defective.
Figure 1: Blood emanating from injection port

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Figure 2: Connector. 1. Normally, 'a' side connects to IV cannula. A. Normal flow of fluids occur. 2. In this case, 'b' side was connected to IV cannula, while 'a' was joined at IV set. B. Valve got displaced inside IV cannula, leading to fluid and blood loss from Injection port

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Medical devices are manufactured under strict vigilance, with stringent guidelines laid down by the International Organization of Standardization. Similarly, IV infusion sets are also covered by the same, under ISO 8536-4 guidelines.[3] IV infusion sets have to fulfil various physical, chemical and biological requirements before being labelled as ISO-standardised. Despite best efforts, some defects such as leakage, breakage and variable flow may still be encountered and their onus lies on the user, hence the need for constant vigilance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lim W, Raghavan K. Identification and confirmation of suspected unintended peripheral arterial cannulation during anaesthesia. Proc Singapore Healthcare 2016;26:203-5.  Back to cited text no. 1
    
2.
Babu S, Laskowski I, Morasch M. Arteriovenous Fistulas Workup: Laboratory Studies, Imaging Studies, Other Tests. [Internet] New York: WebMd LLC; c1994-2019. Available from: https://emedicine.medscape.com/article/459842-workup#c4. [Last Updated on 2017 Nov 10; Last cited on 2019 Jan 31].  Back to cited text no. 2
    
3.
ISO.org [Internet]. Geneva: International Organization for Standardization; c1947. Available from: https://www.iso.org/standard/55799.html. [Last Updated on 2010; Last cited on 2019 Jan 29].  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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