inforMED
InjuryOGE

PERIFIX®

Received Aug 15, 2025 · Event occurred Jun 23, 2025

Report 2521402-2025-00419 · MDR key 22814797

Device

Generic name

Epidural Anesthesia Kit

Catalog number

332200

Product problems

  • Break
  • Break

Patient

60 YR · Male

  • 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 THE USER FACILITY: DETAILED INQUIRY DESCRIPTION: ON MONDAY (B)(6) 2025 A PATIENT HAD AN EPIDURAL CATHETER PLACED INTRAOPERATIVELY FOR PAIN CONTROL FOLLOWING A MULTI-LEVEL POSTERIOR SPINAL FUSION. ON POD 2 WHEN THE PA WAS REVVING THE CATHETER, IT SEPARATED, AND A SECTION OF THE CATHETER REMAINED IN THE PATIENT'S BACK. THE PATIENT RETURNED TO THE OR LATER THAT AFTERNOON FOR AN EXPLORATION OF THE POST-OP LUMBAR WOUND AND REMOVAL OF THE RETAINED EPIDURAL CATHETER. THE SEGMENT WAS SUCCESSFULLY REMOVED. BOTH THE ANESTHESIOLOGIST & THE SURGEON FEEL THAT THE CATHETER WAS DEFECTIVE.

Additional Manufacturer Narrative

THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN MEDICAL INTERNAL REPORT NUMBER (B)(4). A TOTAL OF THREE (3) CATHETERS (ONE USED CATHETER, ONE PARTIAL CATHETER TAPED TO A PAPER, AND ONE PARTIAL CATHETER IN A CONTAINER) WERE PROVIDED FOR EVALUATION. VISUAL EVALUATION OF THE SAMPLES SHOWED THE TWO OF THE THREE CATHETERS TO BE SHEARED OFF. ALTHOUGH TWO CATHETERS WERE OBSERVED TO BE SHEARED, IT WAS NOT CONFIRMED TO BE THE RESULTS OF ANY MANUFACTURING PROCESS. B BRAUN KITS ARE PACKAGED ACCORDING TO BLUEPRINT SPECIFICATIONS WHILE INSPECTING FOR ANY DEFECTS OR DEVIATIONS FROM DRAWING (E.G. EMBEDDED PARTICLES, DIRT, MISSING OR INCORRECTLY ASSEMBLED PARTS, ETC.). IN ADDITION, THERE ARE INCOMING, IN PROCESS AND FINAL FUNCTIONAL INSPECTIONS PERFORMED DURING THE MANUFACTURING OF COMPONENTS AND FINISHED GOOD ITEMS. PER THE MANUFACTURERS INVESTIGATION THIS DEFECT IS NOT LIKELY TO HAVE HAPPENED DURING THE MANUFACTURING PROCESS. THE MOST LIKELY ROOT CAUSE IS DUE TO FURTHER PROCESSING/HANDLING DURING CLINICAL USE 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.