Denny John T, Mungekar Sagar S, Landgraf Benjamin R, Rocke Zoe M, McRae Valerie A, McDonough Christian P, Tse James T, Mellender Scott J, Kiss Geza K
Rutgers University, New Brunswick, NJ, USA.
St. George's University, Grenada, West Indies.
J Investig Med High Impact Case Rep. 2018 Jun 13;6:2324709618781174. doi: 10.1177/2324709618781174. eCollection 2018 Jan-Dec.
We report an unusual case of endotracheal tube failure. It was due to a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Prior to use, the endotracheal tube was tested and functioned normally. A 64-year-old patient in the intensive care unit with a history of hypertension was being mechanically ventilated after uneventful abdominal surgery. After several hours in the intensive care unit, he was noted to be suddenly no longer receiving adequate tidal volumes from the ventilator. It was found that the cuff on the endotracheal tube was not retaining air when it was filled with air from a syringe. This lead to a large "leak" around the endotracheal tube such that the intended tidal volumes set on the ventilator were not delivered to the patient. The patient was uneventfully reintubated and did well. Subsequent investigation revealed the cause to be a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Other mechanisms of cuff failure are reviewed in this case report. This case is an unusual reason for cuff failure. Illustrations supplied alert the reader how to identify the appearance of this manufacturing defect in a pilot balloon. This case illustrates the potential device malfunctions that can develop during a procedure, even when the equipment has been tested and previously functioned well. Even small defects developing in well-engineered products can lead to critical patient care emergencies.
我们报告了一例罕见的气管内导管故障病例。故障原因是内部白色塑料部件存在制造缺陷，该部件通常会被蓝色指示球囊内的鲁尔锁注射器下压。在使用前，气管内导管经过测试且功能正常。一名64岁的重症监护病房患者，有高血压病史，在腹部手术后接受机械通气。在重症监护病房待了几个小时后，发现他突然无法从呼吸机获得足够的潮气量。当用注射器向气管内导管的套囊充气时，发现套囊无法保持空气。这导致气管内导管周围出现大量“漏气”，以至于呼吸机设定的预期潮气量无法输送给患者。患者顺利地重新插管，情况良好。随后的调查发现，原因是内部白色塑料部件存在制造缺陷，该部件通常会被蓝色指示球囊内的鲁尔锁注射器下压。本病例报告还回顾了套囊故障的其他机制。该病例是套囊故障的一个罕见原因。所提供的插图提醒读者如何识别指示球囊中这种制造缺陷的外观。本病例说明了即使设备经过测试且先前功能良好，在手术过程中仍可能出现的潜在设备故障。即使是精心设计的产品出现小缺陷也可能导致危及患者护理的紧急情况。
