MalfunctionBTO
JET VENTILATION CATHETER 13G
Received Jun 23, 2010
Report 8010939-2010-00002 · MDR key 2523084
Device
Product problems
- Occlusion Within Device
- Material Twisted/Bent
Patient
Not reported
- Extubate
Narrative
Description of Event or Problem
THE INNER CATHETER IS REMOVED FROM THE OUTER HUB AFTER INSERTION INTO PT AND DURING THE DISCONNECTION OF THE LUER LOCK CONNECTION. THE INNER CATHETER TWISTED AND OCCLUDED MEANING THAT NO GAS COULD PASS THROUGH THE CATHETER INTO THE PTS LUNGS. THEREFORE PT WAS VENTILATED BY BAG AND MASK, CATHETER REMOVED AND REPLACED UNDER ANESTHETIC BY ONE FROM A DIFFERENT BATCH NUMBER. OPERATION PROCEEDED AND CONCLUDED UNEVENTFULLY.
Remedial action
- Replace