We report a potentially dangerous failure of an epidural loss of resistance syringe that underlines the importance of the thorough checking of all anaesthetic equipment before use. In preparation for epidural catheter insertion into an adult patient using a Portex® Epidural Minipack, 16-G, System 1 (Portex Ltd, Hythe, UK), a careful dynamic check of the loss of resistance syringe revealed excessive resistance. On closer inspection, an accessory web of material was observed at the skirt end of the plunger (Fig. 1). The accessory web became folded back upon itself as the plunger was depressed, thus increasing the friction between the plunger and the barrel. Therefore, excessive force was required to depress the plunger of the loss of resistance syringe, which is normally a lowfriction system. The syringe was returned to the manufacturer. The defect was due to a moulding fault compounded by an inspection error. It was the only reported failure in a production lot of nearly 11 000 units. A new moulding tool has since been commissioned (personal communication with Portex). This case demonstrates the importance of mandatory visual and dynamic checking of all anaesthetic equipment. Manufacturers and clinicians should co-formulate simple, standard checking routines, which are well publicized; indeed, many do this already.
The guidelines of the Association of Anaesthetists of Great Britain and Ireland for checking anaesthetic apparatus  are predominantly ‘airway-equipment’ oriented. We would strongly recommend that a greater emphasis is put upon the checking of non-airwayrelated anaesthetic apparatus in future editions of this document and in any other such guidelines on pre-use equipment checks. This would help reinforce any individual manufacturer's advisory pre-use checks. Inevitably, despite high manufacturing standards, ‘non-airway’ anaesthetic equipment will occasionally prove to be faulty – with potentially dangerous consequences. We need to apply the same rigour to its checking as we do to airway-related equipment.
N. W. Barnes
P. Picton Department of Anaesthesia Southampton General Hospital Southampton, UK
N. W. Barnes Department of Anaesthesia Portsmouth Hospitals NHS Trust Portsmouth, UK
1. Association of Anaesthetists of Great Britain and Ireland. Checklist for Anaesthetic Apparatus
- 2. London, UK: AAGBI, 1997.