inforMED
InjuryFIP

ULTRAFILTER HECHINGEN

Received Jun 5, 2024 · Event occurred May 13, 2024

Report 9611369-2024-00099 · MDR key 19470448

Device

Generic name

Subsystem, Water Purification

Model number

NA

Catalog number

114604

Lot number

3-1802-H-01

Product problems

  • Fluid/Blood Leak
  • Adverse Event Without Identified Device or Use Problem
  • Fluid/Blood Leak
  • Adverse Event Without Identified Device or Use Problem

Patient

42 YR · Unknown

  • Low Blood Pressure/ Hypotension
  • Discomfort
  • Weight Changes
  • Low Blood Pressure/ Hypotension
  • Discomfort
  • Weight Changes

Narrative

Additional Manufacturer Narrative

ADDITIONAL INFORMATION: H6 AND H11. A BATCH REVIEW WAS CONDUCTED AND THERE WERE NO DEVIATIONS FOUND RELATED TO THIS REPORTED CONDITION DURING THE MANUFACTURE OF THIS LOT. THE DEVICE WAS NOT RECEIVED FOR EVALUATION; THEREFORE, A DEVICE ANALYSIS COULD NOT BE COMPLETED. SHOULD ADDITIONAL RELEVANT INFORMATION BECOME AVAILABLE, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.

Description of Event or Problem

IT WAS REPORTED THAT AFTER TWO HOURS OF HEMODIALYSIS TREATMENT WITH A U9000, THE PATIENT EXPERIENCED GENERALIZED SWEATING AND DISCOMFORT. TREATMENT WAS STOPPED IMMEDIATELY. THE PATIENT WAS DISCONNECTED AND "BLOOD TRANSFUSION WAS INITIATED" (REPORTED AS "DISEMBARKED BLOOD TRANSFUSION" [SIC]). THE PATIENT WAS FOUND TO HAVE LOST 2KG IN WEIGHT AND ALSO EXPERIENCED LOW BLOOD PRESSURE. ADDITIONALLY, IT WAS REPORTED THAT ¿THE EVENT CAUSED PATIENT TOO MUCH ULTRAFILTRATION, TOO QUICKLY, CAUSING LOW BLOOD PRESSURE AND EVEN LIFE-THREATENING CONDITIONS¿. UPON INSPECTION OF THE MACHINE, AN EXTERNAL LEAK FROM THE ULTRAFILTER WAS IDENTIFIED. IT WAS REPORTED THAT THE MACHINE WAS REPLACED AND HEMODIALYSIS TREATMENT WAS CONTINUED. NO ADDITIONAL INFORMATION IS AVAILABLE.

Additional Manufacturer Narrative

SHOULD ADDITIONAL RELEVANT INFORMATION BECOME AVAILABLE, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.