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- W1601740599 abstract "We wish to report the failure of a Vygon one-way rotating valve (Ref. 851.00, Vygon [UK] Ltd, Cirencester, UK). Within our hospital, these valves are used to prevent blood reflux whenever an intravenous drip is sited in the same limb as the blood pressure cuff. A patient undergoing elective surgery had a 20 G intravenous cannula inserted in the dorsum of the hand. An infusion of Hartman's solution was connected to the cannula via the one-way valve. At the end of the procedure and after the drapes had been removed, the draw sheet was seen to be blood stained and clear fluid was dripping from the valve. Closer inspection revealed that the red swivel cap plus silicone valve had become dislodged (see Fig. 4). This opened a large orifice through which both fluids were escaping. Fortunately, the estimated blood loss through the faulty valve was small (approximately 20 ml), presumably because of the narrow gauge of the cannula. The patient did not come to any harm. One-way valve set with faulty set and dislodged valve shown below. The risk of bleeding, infection and the loss of administered drugs in such an incident is clear. This last issue is particularly relevant, as these valves are often used during total intravenous anaesthesia. Subsequent examination of another valve, from the same batch, revealed that relatively little force is required to dislodge both the cap and silicone flap valve. This incident may be isolated, or due to a faulty batch. However, we would like to question the usefulness of being able to alter the direction of the one-way valve. By adding this functionality the manufacturer has added an extra level of complexity to the valve, which has caused this critical incident. We would now counsel against the use of these particular valves, especially when the cannula is obscured from view under surgical drapes." @default.
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- W1601740599 date "2004-05-12" @default.
- W1601740599 modified "2023-09-25" @default.
- W1601740599 title "A leaking one-way rotating valve" @default.
- W1601740599 doi "https://doi.org/10.1111/j.1365-2044.2004.03821.x" @default.
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