Biomed Instrum Technol. 2021 Jan 1;55(1):41-43. doi: 10.2345/0899-8205-55.1.41.
Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.
管饲输液中常使用无针、无阀的分隔式隔膜（split septum）医疗器械，这种医疗器械被应用于静脉输液（intravenous，IV）。这些管饲输液器的管帽含有无针、无阀系统，可使液体直接流经导管腔，但当管饲输液器延长管未连接时，可防止液体或血液回流。我们发现，多个患者使用的带有鲁尔（Luer）接头的分隔式隔膜的无针连接器延长套件出现完全故障，原因是尽管管帽两端已连接，但分隔式隔膜仍保持融合且几乎未分开。这导致一名患者出现不良事件，因为反复进行不必要的静脉插入尝试。这个案例表明，即使是最简单的设备也可能出现故障，并强调了在临床实践中保持警惕的必要性。
