inforMED
DeathCBF

MODEL 3200R HYPERBARIC CHAMBER

Received Mar 8, 2010 · Event occurred Feb 2, 2010

Report 2020676-2010-00001 · MDR key 1625920

Device

Generic name

Hyperbaric Chamber

Model number

3200R

Catalog number

3200R

Product problems

  • Normal

Patient

61 YR

  • Anoxia
  • Death
  • Seizures, Grand-Mal

Narrative

Additional Manufacturer Narrative

LETTER RECEIVED FROM HOSPITAL ALONG WITH MEDWATCH FORM INDICATES "... WE DON'T BELIEVE THERE IS ANY PROBLEM WITH THE CHAMBER ... STAFF HAS ALREADY CONTACTED YOU FOR A SERVICE CALL." SERVICE TECHNICIAN SENT TO HOSPITAL TO PERFORM VISUAL INSPECTION AND PERFORMANCE VERIFICATION TO APPROVED FIELD SERVICE PROCEDURE. NO ADJUSTMENTS OR REPAIRS WERE NECESSARY - DEVICE OPERATING TO SPECIFICATIONS.

Description of Event or Problem

THE FOLLOWING WAS PROVIDED DESCRIPTION OF EVENTS TRANSCRIBED FROM LETTER SENT WITH MEDWATCH FORM. "THE PT HAD A HISTORY OF DIABETES MELLITUS, PERIPHERAL ARTERY DISEASE, LEFT BELOW KNEE AMPUTATION, OSTEOMYELITIS OF THE RIGHT FOOT AND STATUS POST RIGHT METATARSAL AMPUTATION. HE'D HAD NUMEROUS TREATMENTS BEFORE THIS DATE. DURING THIS PARTICULAR TREATMENT, HE DEVELOPED A GRAND-MAL SEIZURE THAT WAS SHORT AND PT WAS POST-ICTAL WHEN HE BEGAN TO HAVE AGONAL RESPIRATIONS. OF COURSE, DECOMPRESSION HAD ALREADY BEGUN, BUT HE WAS EMERGENTLY DECOMPRESSED WITH THIS CHANGE. TWO PHYSICIANS WERE IN ATTENDANCE AND CPR WAS ADMINISTERED SUCCESSFULLY WITH ACLS PROTOCOL. THE FOLLOWING DAY, THE PT'S TROPONIN I LEVEL ROSE TO 18.66, HIS EJECTION FRACTION WAS 16% AND HE WAS DIAGNOSED WITH ACUTE ANOXIC ENCEPHALOPATHY. HE DIED ON (B) (6) 2010."

Remedial action

  • Repair