inforMED
InjuryFII

PHOENIX

Received Oct 30, 2008 · Event occurred Aug 1, 2008

Report 2087532-2008-00099 · MDR key 1309603

Device

Generic name

Hemodialysis Equipment

Manufacturer

Gambro Dasco

Model number

PHOENIX

Catalog number

6023006700

Lot number

NA

Product problems

  • Fluid/Blood Leak
  • Output, low

Patient

29 YR

  • Nausea
  • Vomiting
  • Abdominal Cramps
  • Treatment with medication(s)

Narrative

Description of Event or Problem

A PT EXHIBITED SYMPTOMS OF EXCESSIVE WEIGHT REMOVAL WHILE SHE WAS UNDERGOING A ROUTINE DIALYSIS TREATMENT ON A PHOENIX MACHINE. PT REC'D IV FLUIDS IN THE EMERGENCY DEPARTMENT AND WAS DISCHARGED HOME. THE PHOENIX MACHINE WAS PULLED FROM SVC FOR INSPECTION. THE FACILITY'S BIOMED TECH INSPECTED THE MACHINE. A LEAK WAS FOUND IN A SILICONE "L" CONNECTOR AT A PRESSURE TRANSDUCER. THE PRESSURE TRANSDUCER WAS ALSO FOUND TO BE WET AND NOT FUNCTIONAL. BOTH COMPONENTS WERE REPLACED.