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Correspondence  |   December 2007
Potential Hazard Associated with a Laryngoscope Blade
Author Affiliations & Notes
  • Igor Luginbuehl, M.D.
    *
  • *University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
Article Information
Correspondence
Correspondence   |   December 2007
Potential Hazard Associated with a Laryngoscope Blade
Anesthesiology 12 2007, Vol.107, 1037-1038. doi:10.1097/01.anes.0000290616.07193.82
Anesthesiology 12 2007, Vol.107, 1037-1038. doi:10.1097/01.anes.0000290616.07193.82
To the Editor:—
A problem was recently encountered with one of our laryngoscope blades (Classic Mac 3 FO; Heine Optotechnik, Herrsching, Germany) that could have resulted in significant consequences. During cleaning and high-level sterilization of the blade, it was noted that the distal, rounded tip of the blade had become loose to the point where it could easily be detached from the body of the blade (fig. 1). Most anesthesiologists are under the impression that the metal blade is made of one single piece, but in fact the rounded tip is welded onto the blade.
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
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This defective blade was produced in February 2003 and has been used at our hospital on a regular basis since. However, it is not known how many times this particular blade has been used. It is difficult to determine whether the defect resulted from a manufacturing problem or from rough handling (e.g.  , dropping of the blade to the floor). The finding was reported to Heine Canada, Health Canada, and the Federal Drug Administration, and none of them is aware of a similar case.
Independent of the cause, the potential implications for the patient remain the same.
If the blade had been used without the protective tip, this could easily have lead to severe mucosal trauma because the edges of the unprotected blade tip are remarkably sharp and rugged. In the case where the tip would still be attached to the blade upon insertion of the laryngoscope blade into the hypopharynx, the small metal tip could be dislodged during intubation and projected into the tracheobronchial tree, requiring rigid bronchoscopy for removal (if detected immediately) or leading to a significant range of complications, such as segmental atelectasis, obstructive emphysema, pneumonia, or even perforation.
After the detection of the problem, all blades at our institution were inspected, but none was found to have the same defect. Although this seems to be a rare finding, it is recommended to check the integrity of the laryngoscope blade on a regular basis. A quick inspection with manual pulling on the tip may help to prevent serious complications.
*University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
Fig. 1. The loose tip of the laryngoscope blade (partially reattached for illustration purposes) as noticed after cleaning and sterilization. 
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