Anesth Analg 2007;104:1603-1604
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000260514.87058.17
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Defective Double Lumen Tubes: Mallinckrodt the Culprit!
Prabhat Kumar Sinha, MD, and
Thomas Koshy, MD
Department of Anaesthesiology; Sree Chitra Tirunal Institute for Medical Sciences & Technology; Trivandrum; Kerala, India; pksinha{at}sctimst.ac.in
To the Editor:
Recently, we identified a defect consisting of a membranous flap protruding from inside the angle of the Opti-Port Right Angle Connectors (OPTRAC), from four different double lumen tubes (DLTs) being used to provide one lung ventilation. Two additional DLTs with similar defects were found prior to their being used. In two of our patients increased airway pressure along with difficult ventilation developed during one lung ventilation (1,2). Because of this, we performed a literature search for the various types of DLT defects reported.
Using key words double lumen tube, one lung anesthesia, defective DLT, and DLT, nine papers were identified (1–9). Three described defects in nine DLTs similar to those described above (1–3). Two papers reported six cases in which a semicircular protrusion from the plastic tube wall near the point where two separate tubes are joined to form a single double lumen tube (4,5). Two papers reported incorrect labeling of "tracheal" and "bronchial" lumens (6,7). One paper reported reverse assembly of the tracheal tube connectors in one DLT (8). Finally, one paper reported five cases in which ventilation was difficult because of a design fault of left-sided DLTs in which the endobronchial portion has been cut in such a way that the lumen faced the medial wall of the left main stem bronchus and obstructed ventilation during lateral positioning of the patient (9). All of the above defective DLTs were supplied from the same manufacturer i.e., Mallinckrodt (Broncho-Cath, Mallinckrodt Medical Athlone, Ireland).
We suggest that the manufacturer in this case may need to revisit their quality control because the defects described in this report may produce serious complications.
REFERENCES
- Koshy T, Sinha PK, Vijayakumar A. Another defect in right-angle double connector resulting in high peak inspiratory pressure during one lung anesthesia: a simple and practical approach for rapid detection. Anesth Analg 2006;103:1057–8.[Free Full Text]
- Koshy T, Sinha PK, Vijayakumar A, et al. An unusual cause of high airway pressure and inadequate ventilation because of a defective connector despite accurate placement of a double-lumen tube. J Cardiothorac Vasc Anesth 2006;20:627–30.[Web of Science][Medline]
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