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LETTER TO EDITOR
Year : 2016  |  Volume : 60  |  Issue : 11  |  Page : 871  

A peculiar manufacturing defect in catheter mount


Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital and Research Center, Mumbai, Maharashtra, India

Date of Web Publication9-Nov-2016

Correspondence Address:
Alpesh Chhaganlal Bhanushali
Flat No. 5, Sea View Apartments, Chheda Complex, Gate No. 5, Mumbai - 400 095, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.193708

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How to cite this article:
Bhanushali AC, Wagh H. A peculiar manufacturing defect in catheter mount. Indian J Anaesth 2016;60:871

How to cite this URL:
Bhanushali AC, Wagh H. A peculiar manufacturing defect in catheter mount. Indian J Anaesth [serial online] 2016 [cited 2020 Nov 30];60:871. Available from: https://www.ijaweb.org/text.asp?2016/60/11/871/193708

Sir,

Equipment defect has been mentioned in the literature, and it can sometimes lead to patient morbidity if not detected on time. As a result, there has been a great emphasis on checking of the anaesthesia equipment [1] before their use. Guidelines have been formulated by Association of Anaesthetists of Great Britain and Ireland to prevent such mishaps. Here, we would like to mention a case of a catheter mount which had a peculiar manufacturing defect.

A 42-year-old patient with the American Society of Anesthesiologists physical status 1 was posted for laparoscopic inguinal hernioplasty. The catheter mount (Clarimount, product code: 41201, Dashmesh Sonali Healthcare Pvt. Ltd., Mumbai, Maharashtra, India) was kept wrapped until immediately before use, as currently recommended to prevent foreign objects entering and blocking it. After confirming the patient details and attaching routine monitors, it was noticed that the just opened, unbroken, undamaged and patent catheter mount had two patient ends and no machine end as seen in [Figure 1] and [Figure 2]. Timely detection prevented any untoward mishap. Had it been noticed after induction of anaesthesia, it could have resulted in transient apnoea to the patient due to difficulties in mask ventilation as it would be cumbersome to ventilate the patient without the catheter mount.
Figure 1: Catheter mount with two patient ends

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Figure 2: Note the patency at the both ends

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Literature search was conducted using a database of Medline, PubMed, Embase, and Ovid and in Google Scholar. The search terms were 'defective catheter mount', 'catheter mount with two patient ends' and 'blocked catheter mount'. No reference was found on catheter mount with two patient ends, although many references were available for blocked catheter mount. [2],[3],[4],[5]

We place our reliance on the anaesthesia circuit being patent and quality checked before supply, but this incident clearly shows that we cannot take such things for granted. We should, therefore, consider all components, from all manufacturers, as having the potential of being damaged or defective and should be checked before start of any case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dorsch JA, Dorsch SE, editors. Equipment checking and maintenance. In: Understanding Anaesthesia Equipment. 5 th ed. New Delhi: Lippincott Williams and Wilkins, Wolters Kluwer Business; 2008. p. 931-54.  Back to cited text no. 1
    
2.
Ravi PR, Shouche S. A curious case of blocked catheter mount. Med J Armed Forces India 2013;69:313-4.  Back to cited text no. 2
    
3.
Puttick N, Malik D. Blocked catheter mount. Anaesthesia 2007;62:638.  Back to cited text no. 3
    
4.
Thomas R. A blocked catheter mount. Anaesthesia 2001;56:188-9.  Back to cited text no. 4
    
5.
Kapoor H, Date A, Gujarkar K, Wagh H. Defective heat moisture exchange filter causing 'block' in anaesthesia breathing circuit. Indian J Anaesth 2016;60:66-8.  Back to cited text no. 5
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    Figures

  [Figure 1], [Figure 2]



 

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