inforMED
MalfunctionOGE

DESIGN OPTIONS®

Received Oct 30, 2024 · Event occurred Oct 1, 2024

Report 2523676-2024-00958 · MDR key 20567771

Device

Generic name

Epidural Anesthesia Kit

Catalog number

552116

Lot number

0061938651

Product problems

  • Break
  • Difficult to Remove
  • Break
  • Difficult to Remove

Patient

32 YR · Female

  • Foreign Body In Patient
  • Foreign Body In Patient

Narrative

Additional Manufacturer Narrative

THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN MEDICAL INTERNAL REPORT NUMBER (B)(4). THE INVESTIGATION IS ONGOING AT THIS TIME. A FOLLOW-UP WILL BE SUBMITTED WHEN THE INVESTIGATION RESULTS BECOME AVAILABLE.

Description of Event or Problem

AS REPORTED BY USER FACILITY: REGISTERED NURSE (RN) ATTEMPTED TO REMOVE EPIDURAL CATHETER FROM PATIENT'S BACK WHILE PATIENT ON HER SIDE AND MET SIGNIFICANT RESISTANCE. HAD PATIENT CURL AROUND ABDOMEN TO OPEN THE SPINAL SPACE. STILL UNABLE TO REMOVE EPIDURAL CATHETER. RN CALLED ANESTHESIA PROVIDER TO COME EVALUATE. ANESTHESIA PROVIDER'S ATTEMPT TO REMOVE EPIDURAL CATHETER AND ALSO MET SIGNIFICANT RESISTANCE. DUE TO PATIENT NOT HAVING MUCH FEELING IN HER LEGS ANESTHESIA PROVIDER DETERMINED THAT MORE TIME SHOULD BE GIVEN FOR SENSATION TO COME BACK TO PATIENT'S LEGS. 30 MIN LATER ANESTHESIA PROVIDER RETURNED TO PATIENT'S BEDSIDE TO REASSESS PATIENT'S SENSATION IN LEGS. SENSATION HAD IMPROVED AND ANESTHESIA PROVIDER ATTEMPTED TO REMOVE EPIDURAL CATHETER WHILE PATIENT WAS SITTING UP HUNCHED OVER ABDOMEN. ANESTHESIA PROVIDER UNABLE TO REMOVE EPIDURAL CATHETER. HAS PATIENT GET ONTO HANDS AND KNEES AND WAS ABLE TO REMOVE EPIDURAL CATHETER AT THIS POINT, BUT THE TIP OF THE CATHETER DID NOT COME OUT. THE CATHETER APPEARED TO HAVE UNCOILED WHERE IT BROKE OFF AND ANESTHESIA PROVIDER ATTEMPTED TO REMOVE THE REST OF THE CATHETER BUT WAS UNSUCCESSFUL. ANESTHESIA PROVIDER DETERMINED THAT PATIENT WAS STABLE TO MOVE TO POSTPARTUM AND TO PASS ALONG TO THE POSTPARTUM NURSE TO WATCH FOR SIGNS OF INFECTION AND THAT HE WOULD CONTINUE TO FOLLOW UP WITH THE PATIENT ON POSTPARTUM.

Additional Manufacturer Narrative

THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN MEDICAL INTERNAL REPORT NUMBER (B)(4). ONE USED SAMPLE AND EIGHTEEN UNOPENED SAMPLES WERE PROVIDED FOR EVALUATION. UPON VISUAL INSPECTION OF THE RETURNED SAMPLE, THE USED CATHETER SHOWED IT TO BE SHEARED AND KNOTTED. ALL UNUSED CATHETERS WERE REMOVED FROM THE KITS AND VISUALLY INSPECTED. NO DAMAGE, BREAKAGE OR DEFECTS WERE OBSERVED ON ANY CATHETER. BASED ON THE DATA FROM THE INVESTIGATION, THE REPORTED DEFECT WAS UNABLE TO BE CONFIRMED. PER THE MANUFACTURERS INVESTIGATION THIS DEFECT IS NOT LIKELY TO HAVE HAPPENED DURING THE MANUFACTURING PROCESS. IT IS BELIEVED TO HAPPEN DURING APPLICATION. WE WILL MAINTAIN THIS REPORT FOR FURTHER REFERENCES AND CONTINUE TO MONITOR OTHER REPORTS FOR SIMILAR OCCURRENCES. IF ANY ADDITIONAL PERTINENT INFORMATION BECOMES AVAILABLE, A FOLLOW UP WILL BE SUBMITTED.