Cap mount confusion in a DAR TM HME Filter
S. Sanderson, A. Ball · Anaesthesia · 2016
We would like to raise a safety issue about the design of the DarTM Adult-Paediatric Electrostatic Filter HME (Covidien-Medtronic, Minneapolis, MN, USA). After connection of a patient transferred from intensive care to a ventilator in theatres, no end-tidal carbon dioxide was detected. After initial concerns about the effectiveness of ventilation, we noted the sampling tube had been attached inadvertently to a round plastic protuberance on the filter, rather than to the sampling lumen (Fig. 3). The sampling line was reconnected correctly and no harm occurred to the patient. The manufacturer states that this is a ‘cap mount’ and is designed to be used as docking site for the cap of the sample lumen. It is, therefore, a similar size and shape to the sampling lumen, and so confusion is easy. Although anaesthetists should always check their equipment before use, we think a significant clinical risk could occur in the event of a difficult intubation or cardiac arrest. We contacted the manufacturer about this risk, but they replied that they are not planning any redesign. We have reported this incident to the Medicines and Healthcare products Regulatory Agency.