88
Correspondence
A 36-year-old women presented with low abdominal pain and a radiological examination of the colon revealed an intra-abdominal foreign body which looked like the nozzle of a Xylocaine spray. At laparotomy the nozzle was found to be lying partly in the caecum having perforated its wall. The patient recovered uneventfully. Her notes record that she had, 16 months earlier, undergone surgery for varicose veins and that the anaesthetist had, on that occasion, used a Xylocaine spray prior to intubation. We would like to emphasise the care which must be exercised when using this type of spray; it should be re-designed to prevent further mishaps of this nature. Hospital Priisado, Barrio Parqiw V. Sarsfii~ld, SO00 Cdrdoba, Argentina
A reply /i.oni Astra Liikemedd A B
We are grateful for the opportunity to comment on the letter from Drs J. Pogulanik and B.A. Castro. During the last years the spray nozzle described i n the letter from Drs J. Pogulanik and B.A. Castro has been substituted by a new type having a threaded portion of the tube within the plastic hub of thc spray bottle. Compared with the old design this modification has been found to safeguard the nozzle from coming loose. There are some countries, however, where this modification has not yet been introduced. One possible risk with the old type nozzle is that it may partially melt the plastic hub material if introduced into the hub hole immediately after heat sterilization, causing an enlargement of the hub hole and hence reduced retention of the nozzle. A new J. POGULANIK delivery system (without freon propellant) is being B.A. CASTRO developed and all attention will be given to ensure safety in clinical use. Astra Lakemedel A B, S-IS18.5 Scdertiilje, Sweden
ANDERS UPPFELDT (Information Manager)
Hazards of circle absorbers Rebreathing circle absorber systems offer advantages in economy, lack of pollution and (perhaps less importantly now), explosion hazards. In contrast to Britain, they are widely used in Australasia. Hazards of their use are numerous. The misconnection of the rebreathing bag to the inspiratory port,’ the expiratory port,2 and failure to vent excess gas when connected to a ventilator3 all lead to covert increase in circuit pressure and pneumothorax. Contamination of the circuit with soda lime has also long been recognised but two recent reports from North America emphasise that this problem has not been overcome. The one was due to design fault (with fresh gas flow coming in at the base of the a b ~ o r b e r ) , ~ the other to a routine testing procedure of overdistension of the rebreathing bag.’ This latter manoeuvre is recommended by the Royal Australasian College of Surgeons6 as part of the preanaesthetic ‘cockpit check’. Unidirectional valves have also been shown to be a problem and two cases of ‘to and fro’ rebreathing due to poorly re-assembled valves were recently rep~rted.’.~ I can find no reports in the recent literature of a valve dome which spontaneously disintegrated (Fig. 1). There was no immediate preceding trauma to the dome. It had appeared to be sound and had passed the ‘cockpit check’ test of the breathing circuit, before use.6 Internal pressure would be minimal as the patient was holding the mask in preoxygenation for a Caesarean Section. There was
nobody near the valve when it failed. It will be noted, however, that the valve dome is of an older type (here from a Boyle Mk. 2 absorber), many of which are still in use although the modern dome is made of plastic. The immediate tell-tale sign here was the tinkling of the broken glass. The deflation of the rebreathing bag in spontaneous respiration or the respiration or the loss of pressure during IPPV should be readily apparent. Department of Anaesthetics, Waikato Hospital, Hamilton, New Zealand
D.R. DERBYSHIRE
References
I . BARAKA, A. (1975) Misconnection of Boyle Circuit Tubings. Anaesthesia and Intensive Care, 3, 260. 2. RINGROSE. N.H. (1974) Design of Boyle Absorber. Anaesthesia and Intensive Care, 2, 269.
3. SEARS, B.E. & BOCAR, N.D. (1977) Pneumothorax resulting from a closed Anaesthesia Ventilator Port. Anethesiolngy, 47, 31 1 . 4. LAURIA, J.I. (1975) Soda lime dust contamination of breathing circuits. Anesthesiology, 47, 628. 5 . DEBBAN, D.G. & BEDFORD,
R.F. (1975) Overdistension of the rebreathing bag a hazardous test for circle system integrity. Anesthesiology, 42, 356. 6. MAINLARD, J. & DUDLEY, H. (1976) Safety in the Operating Theatre, 1st edn, p. 88. Edward Arnold, Melbourne.
Correspondence
89
Fig. 1
7. SCHWEITZER, S.A. & BABARCZY,A.J. (1976) An unexpected hazard of the Boyle’s machine. Anarsfhesia and Infensive Care, 4, 72.
8. SCHWEITZER, S.A. & DOMAINGUE, C.M. (1978) A
further hazard of the Boyle’s Machine. Anaesthesia and Infensiue Care, 6 , 84.
Failure of a ‘Y’connector An apparatiis failure
I would like to report a potentially dangerous incident concerning a ‘Y’ connector. During the course of an anaesthetic, the ‘Y’ connector, illustrated in Fig. 1, separated at the ‘welded’ joint completely cutting the patient off from the anaesthetic supply. This ‘Y’ piece was attached to an absorber circuit on a Blease Major anaesthetic machine which was practically new and had only been in use for two months. At the time of the failure the circle absorber circuit was in use on a patient undergoing minor breast surgery and the fault was quickly detected. However, the danger is an obvious one in patients undergoing head and neck surgery and dental work where the ‘Y’ connector would be concealed from
the anaesthetist by sterile drapes. It would of course be particularly hazardous in cases receiving mechanical ventilation where, unless rapidly detected, the consequences could be fatal. It is also interesting to note that this type of joint appears frequently in other pieces of anaesthetic equipment. Clatterbridge Hospital, Clatterbridge Road, Bebbington, Wirral, Merseyside L63 4J Y
VICTORIA PETTS
A reply from the supplier
Blease does not manufacture ‘Y’pieces. The
Correspondence
A 36-year-old women presented with low abdominal pain and a radiological examination of the colon revealed an intra-abdominal foreign body which looked like the nozzle of a Xylocaine spray. At laparotomy the nozzle was found to be lying partly in the caecum having perforated its wall. The patient recovered uneventfully. Her notes record that she had, 16 months earlier, undergone surgery for varicose veins and that the anaesthetist had, on that occasion, used a Xylocaine spray prior to intubation. We would like to emphasise the care which must be exercised when using this type of spray; it should be re-designed to prevent further mishaps of this nature. Hospital Priisado, Barrio Parqiw V. Sarsfii~ld, SO00 Cdrdoba, Argentina
A reply /i.oni Astra Liikemedd A B
We are grateful for the opportunity to comment on the letter from Drs J. Pogulanik and B.A. Castro. During the last years the spray nozzle described i n the letter from Drs J. Pogulanik and B.A. Castro has been substituted by a new type having a threaded portion of the tube within the plastic hub of thc spray bottle. Compared with the old design this modification has been found to safeguard the nozzle from coming loose. There are some countries, however, where this modification has not yet been introduced. One possible risk with the old type nozzle is that it may partially melt the plastic hub material if introduced into the hub hole immediately after heat sterilization, causing an enlargement of the hub hole and hence reduced retention of the nozzle. A new J. POGULANIK delivery system (without freon propellant) is being B.A. CASTRO developed and all attention will be given to ensure safety in clinical use. Astra Lakemedel A B, S-IS18.5 Scdertiilje, Sweden
ANDERS UPPFELDT (Information Manager)
Hazards of circle absorbers Rebreathing circle absorber systems offer advantages in economy, lack of pollution and (perhaps less importantly now), explosion hazards. In contrast to Britain, they are widely used in Australasia. Hazards of their use are numerous. The misconnection of the rebreathing bag to the inspiratory port,’ the expiratory port,2 and failure to vent excess gas when connected to a ventilator3 all lead to covert increase in circuit pressure and pneumothorax. Contamination of the circuit with soda lime has also long been recognised but two recent reports from North America emphasise that this problem has not been overcome. The one was due to design fault (with fresh gas flow coming in at the base of the a b ~ o r b e r ) , ~ the other to a routine testing procedure of overdistension of the rebreathing bag.’ This latter manoeuvre is recommended by the Royal Australasian College of Surgeons6 as part of the preanaesthetic ‘cockpit check’. Unidirectional valves have also been shown to be a problem and two cases of ‘to and fro’ rebreathing due to poorly re-assembled valves were recently rep~rted.’.~ I can find no reports in the recent literature of a valve dome which spontaneously disintegrated (Fig. 1). There was no immediate preceding trauma to the dome. It had appeared to be sound and had passed the ‘cockpit check’ test of the breathing circuit, before use.6 Internal pressure would be minimal as the patient was holding the mask in preoxygenation for a Caesarean Section. There was
nobody near the valve when it failed. It will be noted, however, that the valve dome is of an older type (here from a Boyle Mk. 2 absorber), many of which are still in use although the modern dome is made of plastic. The immediate tell-tale sign here was the tinkling of the broken glass. The deflation of the rebreathing bag in spontaneous respiration or the respiration or the loss of pressure during IPPV should be readily apparent. Department of Anaesthetics, Waikato Hospital, Hamilton, New Zealand
D.R. DERBYSHIRE
References
I . BARAKA, A. (1975) Misconnection of Boyle Circuit Tubings. Anaesthesia and Intensive Care, 3, 260. 2. RINGROSE. N.H. (1974) Design of Boyle Absorber. Anaesthesia and Intensive Care, 2, 269.
3. SEARS, B.E. & BOCAR, N.D. (1977) Pneumothorax resulting from a closed Anaesthesia Ventilator Port. Anethesiolngy, 47, 31 1 . 4. LAURIA, J.I. (1975) Soda lime dust contamination of breathing circuits. Anesthesiology, 47, 628. 5 . DEBBAN, D.G. & BEDFORD,
R.F. (1975) Overdistension of the rebreathing bag a hazardous test for circle system integrity. Anesthesiology, 42, 356. 6. MAINLARD, J. & DUDLEY, H. (1976) Safety in the Operating Theatre, 1st edn, p. 88. Edward Arnold, Melbourne.
Correspondence
89
Fig. 1
7. SCHWEITZER, S.A. & BABARCZY,A.J. (1976) An unexpected hazard of the Boyle’s machine. Anarsfhesia and Infensive Care, 4, 72.
8. SCHWEITZER, S.A. & DOMAINGUE, C.M. (1978) A
further hazard of the Boyle’s Machine. Anaesthesia and Infensiue Care, 6 , 84.
Failure of a ‘Y’connector An apparatiis failure
I would like to report a potentially dangerous incident concerning a ‘Y’ connector. During the course of an anaesthetic, the ‘Y’ connector, illustrated in Fig. 1, separated at the ‘welded’ joint completely cutting the patient off from the anaesthetic supply. This ‘Y’ piece was attached to an absorber circuit on a Blease Major anaesthetic machine which was practically new and had only been in use for two months. At the time of the failure the circle absorber circuit was in use on a patient undergoing minor breast surgery and the fault was quickly detected. However, the danger is an obvious one in patients undergoing head and neck surgery and dental work where the ‘Y’ connector would be concealed from
the anaesthetist by sterile drapes. It would of course be particularly hazardous in cases receiving mechanical ventilation where, unless rapidly detected, the consequences could be fatal. It is also interesting to note that this type of joint appears frequently in other pieces of anaesthetic equipment. Clatterbridge Hospital, Clatterbridge Road, Bebbington, Wirral, Merseyside L63 4J Y
VICTORIA PETTS
A reply from the supplier
Blease does not manufacture ‘Y’pieces. The
