Complications associated with introduction of new neuraxial equipment

We read with great interest the recent editorial and paper regarding new connectors in neuraxial anaesthesia [1, 2]. Our institution recently replaced all epidural kits with a new product (Flex Tip Plus® Epidural Catheter; Arrow International UK Ltd., Uxbridge, Middlesex, UK). We had two equipment failures soon afterwards. During transfer of a patient from the operating table to a trolley, the epidural filter and catheter looked intact; there had been no obvious traction applied to the catheter. Before transport to recovery, we noted that the catheter had sheared at a point external to the patient. In a second patient, the 20-ml Luer-slip syringe provided in the kit was filled with bupivacaine and connected to the epidural filter using minimal force. On disengaging the syringe, we noted that the tip had sheared off into the filter. The National Patients Safety Agency’s (NPSA) drive for implementing new neuraxial connectors by 2013 [3] may be in patients’ best interests; however, in our department, we had two incidents with tried and tested equipment, probably related to unfamiliarity. Introduction of new neuraxial connectors may well lead to further problems. We believe the introduction of new neuraxial equipment must be done cautiously and with active formal evaluation of adverse clinical outcomes. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com