inforMED
InjuryKDI

PRISMAX MACHINES

Received Jul 17, 2026 · Event occurred Jun 24, 2026

Report 9616240-2026-00025 · MDR key 25856752

Device

Generic name

Dialyzer, High Permeability With Or Without Sealed Dialysate System

Model number

NA

Catalog number

955725

Lot number

NA

Product problems

  • Device Alarm System
  • No Visual Prompts/Feedback

Patient

NA · Unknown

  • Hemorrhage/Blood Loss/Bleeding
  • Low Blood Pressure/ Hypotension

Narrative

Additional Manufacturer Narrative

SHOULD ADDITIONAL RELEVANT INFORMATION BECOME AVAILABLE, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.

Description of Event or Problem

IT WAS REPORTED THAT DURING CONTINUOUS RENAL REPLACEMENT THERAPY WITH A PRISMAX MACHINE, A CALL SERVICE ALARM (SYSTEM FAILURE) WAS TRIGGERED. THE MACHINE WAS REBOOTED, HOWEVER THE SCREEN BECAME UNRESPONSIVE AND TREATMENT COULD NOT BE RESUMED. AFTER RESTARTING TREATMENT WITH A NEW SET, THE SCREEN BECAME UNRESPONSIVE AGAIN. ON BOTH OCCASIONS, THE TREATMENT WAS ENDED WITHOUT THE EXTRACORPOREAL BLOOD BEING RETURNED TO THE PATIENT. AFTER A REPORTED CUMULATIVE BLOOD LOSS OF APPROXIMATELY 500ML, THE PATIENT BECAME "PROFOUNDLY" HYPOTENSIVE, WITH AN ESTIMATED MEAN ARTERIAL PRESSURE OF 40MMHG. THE PATIENT WAS TREATED WITH A METARAMINOL INFUSION AND ADDITIONAL BOLUSES. ADEQUATE BLOOD PRESSURE COULD NOT BE MAINTAINED, AND THE PATIENT WAS TRANSITIONED TO A DOUBLE-STRENGTH NORADRENALINE INFUSION. NO ADDITIONAL INFORMATION IS AVAILABLE.