inforMED
MalfunctionFPB

MEDEX IV FILTER EXTENSION SET

Received Feb 27, 2024 · Event occurred Oct 5, 2023

Report 9616567-2024-00037 · MDR key 18793665

Device

Generic name

Filter, Infusion Line

Catalog number

FS116

Lot number

UNKNOWN

Product problems

  • Fluid/Blood Leak
  • Fluid/Blood Leak

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

B1, B2, H1 AND H2 - UPDATED.

Additional Manufacturer Narrative

DEVICE EVALUATION: NO PRODUCT OR PHOTOS WERE RETURNED THEREFORE NO DEVICE ANALYSIS COULD BE COMPLETED. A DEVICE HISTORY RECORD (DHR) REVIEW COULD NOT BE PERFORMED AS THE LOT NUMBER WAS UNKNOWN. IF THE PRODUCT IS RETURNED THE MANUFACTURER WILL RE-OPEN THE COMPLAINT FOR FURTHER DEVICE ANALYSIS.

Additional Manufacturer Narrative

D4: LOT NUMBER, EXPIRATION DATE, E1: PHONE, AND H4: DEVICE MANUFACTURE DATE ARE UNKNOWN, NO INFORMATION HAS BEEN PROVIDED TO DATE. H3: OTHER; DEVICE NOT RETURNED TO MANUFACTURER. INVESTIGATION INCLUDING ROOT CAUSE ANALYSIS IS IN PROGRESS. A SUPPLEMENTAL MDR WILL BE FILED AS NECESSARY IN ACCORDANCE WITH 21 CFR 803.56 WHEN ADDITIONAL REPORTABLE INFORMATION BECOMES AVAILABLE.

Description of Event or Problem

IT WAS REPORTED THAT THERE WAS "A TREND OF MALFUNCTIONING FILTER MICROBORE INTRAVENOUS INFUSION TUBING THAT BEGAN STARTING 2023. THE TUBING LEAKS AT THE FILTER OR REQUIRES EXCESS PRESSURE TO PRIME/INFUSE FLUID. HAS IMPACTED FLOW OF MEDICATIONS SUCH AS INOTROPES AND SEDATION ON CRITICALLY ILL PEDIATRIC CARDIOVASCULAR PATIENTS IN THE OPERATING ROOM OR INTENSIVE CARE UNIT. ONE PATIENT IN 2023 HAD EPINEPHRINE LEAKING IN THE OPERATING ROOM DURING OPEN HEART SURGERY, POSSIBLY CONTRIBUTING TO A DELAY IN COMING OFF OF BYPASS. RE-ESCALATED TO THE MANUFACTURER ON THAT DAY, AND THEY CAME ON SITE 2023 TO RETRIEVE PRODUCT. AT THAT TIME, THEY MENTIONED THAT THE FILTER IS PROVIDED BY ANOTHER COMPANY. HAVE NOT STOPPED USE OF THE PRODUCT BUT HAVE RE-EDUCATED STAFF ON THE MANUFACTURER'S INSTRUCTIONS FOR USE WITH ONGOING ISSUE." THERE WAS NO PATIENT HARM REPORTED. NO PATIENT NAMES AVAILABLE. PRODUCT FAILURES OCCURRED DURING INFUSION, NOTICED HOURS OR DAYS INTO INFUSION.