NEUROSTAR ADVANCED THERAPY SYSTEM
Received Jun 11, 2024 · Event occurred May 29, 2024
Report 3004824012-2024-00016 · MDR key 19511418
Device
Generic name
Transcranial Magnetic Stimulator
Manufacturer
Neuronetics, Inc.Model number
NEUROSTAR ADVANCED THERAPY SYSTEM V3.0Catalog number
81-01335-000
Product problems
- Use of Incorrect Control/Treatment Settings
- Use of Incorrect Control/Treatment Settings
Patient
35 YR · Male
- Nausea
- Syncope/Fainting
- Nausea
- Syncope/Fainting
Narrative
Additional Manufacturer Narrative
NEURONETICS WAS CONTACTED BY A PROVIDER REPORTING THAT ONE OF THEIR PATIENTS BECAME NAUSEOUS DURING HIS FIRST TREATMENT SESSION AND TREATMENT WAS PAUSED. THE PATIENT BEGAN BURPING BEFORE PASSING OUT. PATIENT REPORTEDLY EXPERIENCED A BRIEF PERIOD OF SHAKING BEFORE QUICKLY "FALLING ASLEEP". THE PROVIDER ASSESSED THE PATIENT AND CONCLUDED THAT PATIENT MOST LIKELY EXPERIENCED A VASOVAGAL RESPONSE BUT SENT PATIENT TO THE EMERGENCY ROOM FOR FURTHER EVALUATION. PATIENT WAS NOTED TO HAVE A HISTORY OF SYNCOPAL EPISODES WITH THE MOST RECENT OCCURRING IN (B)(6) 2024. UPON INVESTIGATION, THE TREATMENT LOCATION THAT WAS USED SUGGESTS THAT THE COIL PLACEMENT MAY HAVE BEEN TOO CLOSE TO THE PATIENT'S MOTOR STRIP BASED ON THE PATIENT'S STATURE AND SIZE WHICH COULD HAVE RESULTED IN THE REPORTED ADVERSE EVENT. PATIENT WILL BE FOLLOWING UP WITH CARDIOLOGY FOR CLEARANCE TO RETURN TO TREATMENT AS THIS IS THE PATIENT'S SECOND SYNCOPAL EPISODE WITHIN A 3-MONTH PERIOD.
Description of Event or Problem
NEURONETICS WAS CONTACTED BY A PROVIDER THAT REPORTED ONE OF THEIR PATIENTS BECAME NAUSEOUS AND PROCEEDED TO PASS OUT DURING HIS FIRST TREATMENT SESSION. THE TREATER NOTED THAT WHILE THE PATIENT WAS PASSED OUT, HE EXPERIENCED A PERIOD OF "BRIEF SHAKING" BEFORE FALLING "INTO A DEEP SLEEP" AND BEGAN TO SNORE. PATIENT WAS SENT TO THE ER AS A PRECAUTION.