Inappropriately sized connector: An ingredient for catastrophe!?

Madam,

Pre-use check of endotracheal tube (ETT) is a routine anesthesia practice. Despite this, manufacturing defects are frequently encountered which can go unnoticed on visual inspection and may lead to catastrophic situations.[1]

We report one such case of a 54-year-old female (weight 75 kg) posted for laparoscopic cholecystectomy. Following the induction of general anesthesia as per local standards, patient was intubated with 7.5 mm Internal Diameter (ID) ETT (Sterimed Health Care Technologies, LLC, Florida, USA, manufactured at Sterimed Medical Devices Ltd. Bahadurgarh, Haryana). While connecting the ETT to the circuit of anesthesia machine, we found that the connection was loose and circuit was being easily disconnected from the tube. The connection was held manually to ventilate the patient. In the meantime, a properly fitting new connector of same size ETT (different manufacturer) was arranged. Since, the faulty connector could not be removed from the tube; it was not possible to replace it with the new connector. To prevent frequent intraoperative disconnections, we applied a layer of micropore adhesive over the connector [Figure 1]. The connector now fitted snugly into the circuit and remained connected during rest of the surgery.

Figure 1

A layer of micropore adhesive applied to the endotracheal tube connector

Postoperatively, the connector was measured using a digital Vernier caliper and was found to be of smaller size (14.76 mm) in contrast to 15 mm standard connector [Figure 2]. The difference was small, but clinically significant.

Figure 2

Measurement of the connector in question (a) and a standard connector (b) using digital vernier caliper

There are many reports in literature where manufacturing defects involving the cuff inflation system or patency of connectors have been described.[2345] All these reports emphasize on pre-use check for cuff leak and tube patency. The routine check of airway connectors for circuit compatibility has not been recommended as their size has been standardized (15 mm diameter) so that all airway devices are readily connectable to anesthesia circuit. The manufacturing defect in connectors can prove to be catastrophic especially in difficult airway scenarios where replacement of ETT may be challenging. Such incidents raise a concern regarding need for more stringent quality checks.

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