Complete obstruction to flow in a three-way stopcock due to a manufacturing defect

摘要

Recently, when preparing our heated intravenous sets for intraoperative use, we detected a series of defective three-way stopcocks (MX5311L, Smiths Medical, Dublin, OH, USA) that caused complete obstruction to flow. Our typical heated fluid line setup includes a three-way stopcock placed between a set of heated tubing (Hotline? L-70) and a 30-in tubing extension connected to an intravenous cannula. Every morning, our anesthesia technicians routinely prepare batches of these sets for use throughout the day. Although these intravenous sets had been adequately de-aired and all the clamps were fully opened, we noticed that several were obstructed to passive gravity fed flow. Initially, our technicians were rejecting all three components and disposing of the entire setup.