Use of the Airtraq with a fibreoptic bronchoscope in a difficult intubation outside the operating room.

CAN J ANESTH 55: 8 www.cja-jca.org August, 2008 ment with a bolus, followed by continuous infusion of naloxone, and tracheal intubation was not needed. Subsequent testing of the PCA determined that, when the door of the PCA was closed, due to a defect in the pump, there was unintended pressure on the free flow protection device which allowed for free flow. This defect was not visible to the naked eye. Following this event, all the PCA machines in the hospital were evaluated by the manufacturer, and none was found to have this defect. The same pumps are still used in our hospital, and there have been no reported recurrences. Following this case, our protocol for attaching the PCA was changed, such that, after PCA set up, there is a specific examination to test for the absence of free flow, prior to attaching the tubing to the intravenous line of the patient. In the event described in this letter, the PCA tubing was clamped until after it had been attached to the patient’s intravenous tubing. This experience further emphasizes that a free flow protection device is not infallible, and regardless of manufacturer, the absence of free flow should be confirmed prior to attaching the PCA to the patient.