inforMED
MalfunctionBTM

SPUR II ADULT FOR DEMAND VALVE

Received Jul 13, 2021 · Event occurred Jun 10, 2021

Report 1220828-2021-00012 · MDR key 12162764

Device

Generic name

Manual Resuscitator

Catalog number

325023000

Lot number

1927634, 1883919

Product problems

  • Connection Problem
  • Material Twisted/Bent

Patient

Not reported

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

TWO AFFECTED DEVICES WERE RETURNED TO THE MANUFACTURER FOR INVESTIGATION. THE REPORTED FAILURE WAS VERIFIED BY VISUAL INSPECTION OF THE DEVICES. PRODUCTION AND QC RECCORDS FOR THE APPLICABLE LOTS WERE CHECKED. NO ABNORMALITIES WHERE NOTED. HENCE, THE SPUR II RESUSCITATORS WERE IN GOOD STATE WHEN LEAVING THE FACTORY. THE MOST LIKELY ROOT CAUSE OF THE DEFORMATION IS LONG TIME STORAGE IN A COMPRESSED STATE WITH TIGHT CONNECTION OF OXYGEN NIPPLE AND OXYGEN TUBE. THE REPORTED ISSUE IS EASILY IDENTIFIABLE DURING THE PRESCRIBED PRECHECK OF THE DEVICE PRIOR TO USE ON PATIENT.

Description of Event or Problem

OXYGEN FLOW VIA TUBING FROM THE OXYGEN WALL CONNECTION INTO THE RESERVOIR BAG OF THE SPUR II WAS NOT POSSIBLE BECAUSE THE CONNECTION POINT ON THE RESERVOIR BAG WAS BENT, FUSED AND INTERNALLY TIGHT. AFTER IDENTIFYING THE PROBLEM, ALL SETS WERE REVIEWED IN THE OR AND SEVERAL RESERVOIR BAGS WITH THE SAME PROBLEM WERE IDENTIFIED AND REPLACED. THE PATIENT CONDITION WAS NOT AFFECTED. WHILE ONE FAULTY DEVICE DOES NOT POSE A RISK OF SERIOUS HEALTH DETERIORATION AS THE SPUR II WILL STILL BE ABLE TO PROVIDE RESUSCITATION WITH AMBIENT AIR (21% OXYGEN) UNTIL A BACK UP RESUSCITATOR HAS BEN READIED FOR USE, THE PATIENT IS AT RISK OF HYPOXIA WHEN THE BACK UP DEVICE ALSO FAILS TO DELIVER HIGH OXYGEN CONCENTRATION.