inforMED
InjuryFLL

MATRIX12 M ESOPHAGEAL TEMPERATURE PROBE

Received May 22, 2025 · Event occurred Apr 18, 2025

Report 3009437315-2025-00002 · MDR key 22071935

Device

Generic name

Esophageal Temperature Probe

Model number

CS-31EP

Lot number

14660

Product problems

  • Use of Device Problem
  • Use of Device Problem

Patient

NA · Unknown

  • Unspecified Tissue Injury
  • Unspecified Tissue Injury

Narrative

Additional Manufacturer Narrative

NO TESTING COULD BE PERFORMED AS PROBE WAS NOT RETURNED. BASED ON SIMILAR COMPLAINT TESTING, THERE IS NO KNOWN DEFECT THAT WOULD PREVENT PROPER PLACEMENT. ROOT CAUSE IS USER DID NOT APPEAR TO FOLLOW INSTRUCTIONS FOR USE AND VERIFY PROPER PLACEMENT WITH FLUOROSCOPY OR 3D MAPPING SYSTEM.

Description of Event or Problem

ANESTHESIOLOGIST BELIEVED THAT PROBE WAS PLACED IN THE BRONCHUS AND BLEEDING OCCURRED UPON REMOVAL. PATIENT HAD TO REMAIN INTUBATED, HAD A BRONCH DONE AND WAS EXTUBATED ON MONDAY (B)(6).