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We should like to report an incident that occurred whilst performing spinal anaesthesia in an elderly patient using one of the new ‘non-Luer’ type needles [1].

The kit (Pajunk® UK Medical Products Ltd, Prestwick, Northumberland, UK) came with two non-Luer syringes, 5- and 2-ml, a 24-G spinal needle with an introducer and a (Luer) drawing-up needle that was connected to a Luer/non-Luer adaptor.

A mixture of levobupivacaine and fentanyl was drawn up into the non-Luer 5-ml syringe. Lidocaine 1% was drawn up into the 2-ml syringe but there was no needle for skin infiltration. The anaesthetic assistant suggested that the adapter may come apart (Fig. 6) from the drawing-up needle. With a little persuasion it came apart and the 25-G skin needle was then attached to the adapter and the 2-ml syringe.

The spinal was attempted with the 24-G non-Luer needle, but as could be predicted was unsuitable for an older person's back. The assistant produced the tried and tested (Luer) BD 22-G needle (Becton Dickinson UK Ltd, Oxford, UK), which was immediately successful in locating the subarachnoid space. Using the adapter that had been removed from the drawing-up needle, the non-Luer 5-ml syringe was connected to the Luer needle and a successful block was completed.

The anaesthetic assistant then remarked “Why bother with these new devices if you can get the old stuff to fit on as well?”

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Figure 6. Non-Luer spinal needle pack (a) and Luer drawing-up needle with non-Luer adaptor (b) attached and (c) after separation.

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We are grateful for the chance to analyse the subject of Griffiths and Jubb's report.

Glueing adaptor parts to individual components is part of the manufacturers' risk management evaluation. The glue connection is tested and specified to resist an average of 200 N. It appears that in this case the end-user intentionally altered the device by destroying the glue connection, applying inappropriate force. Any medical device that is modified before use is defined as ‘in-house’ manufacturing at the hospital and such a device no longer constitutes a Pajunk devivce.&authnm;