I would like to bring to the attention of your readers a serious failure of a minor piece of apparatus, which, if unrecognised, could have dangerous sequelae. Whilst anaesthetising a 74-year-old ASA 4 patient in the prone position for major urulogical surgery, I noticed that in spite of varying both inspired minute and tidal volume in a patient who otherwise appeared to be eminently stable, the pE’co2 remained in the region of 1.7-2.2 kPa. Upon checking all anaesthestic variables, no abnormality could be found. The monitoring system, a Cardiocap I1 CGlGS was then recalibrated, using a factory specification gas cylinder (and found to be correct) yet the pElcoz remained low. Examination of the monitoring line-Intersurgical 2732-revealed a partial break where the tubing entered the Luer lock connection (Fig. 1). Changing this tubing returned the pE’co2 to normal. During the subsequent week, this defect was detected on four separate occasions and is obviously due to a defect in the manufacturing process in that the tubing pulls away from the connector on minimal angulation. It is my view that this product should not be used until modified.
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