Abstract
Editor'During a routine paediatric orthopaedic list, it was brought to my attention that the size 7-mm cuffed Portex tracheal tube to be used for the next patient was defective. Whilst testing the tube, the operating department practitioner noted a foreign body within the folds of the cuff (Fig. 1). This foreign body was a plastic oval, which had been cored out in the production of the Murphy eye (Fig. 2). The disc is clear plastic and radiolucent; if aspirated it would prove difficult to locate. Obviously, if this defect had not been observed, and the tracheal cuff not test inflated before insertion, the sequelae could have been catastrophic. The manufacturer has since been notified and is investigating the incident. A brief literature search found no reports of a similar nature. This case provides a useful reminder to be vigilant and check all equipment before use.Fig 2Remnant of Murphy eye.View Large Image Figure ViewerDownload (PPT)
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