inforMED
MalfunctionFIL

FRESENIUS DIALYSIS DELIVERY SYSTEM

Received Mar 6, 2002 · Event occurred Feb 15, 2002

Report 2937457-2002-00018 · MDR key 381382

Device

Generic name

Hemodialysis Machine

Model number

2008K

Catalog number

NA

Lot number

NA

Product problems

  • Replace
  • Insufficient Flow or Under Infusion

Patient

UNKNOWN

  • Low Blood Pressure/ Hypotension
  • Therapy/non-surgical treatment, aborted/stopped
  • Treatment with medication(s)
  • Weight Changes

Narrative

Description of Event or Problem

FRESENIUS MEDICAL CARE CANADA, INC. REPORTED THAT THERE WAS EXCESS FLUID REMOVED FROM A PATIENT DURING A HEMODIALYSIS TREATMENT. THE PATIENT BECAME HYPOTENSIVE 30 MIN. INTO THE TREATMENT. BLOOD IN THE EXTRACORPOREAL CIRCUIT WAS NOTED TO BE DARK. THE PATIENT WAS GIVEN SALINE AND WAS WEIGHED AT THIS TIME. BASED ON THE REPORTED WEIGHTS AND WHAT THE MACHINE INDICATED WAS REMOVED, THERE WAS A WEIGHT LOSS VARIANCE OF APPROX 2.7 KG. TREATMENT WAS CONTINUED ON ANOTHER MACHINE WITH NO FURTHER PROBLEM. THERE WAS NO SERIOUS INJURY OR ILLNESS.