NON LATEX MILLER AIR TIP
Received Aug 21, 2014 · Event occurred Jul 16, 2014
Report 2411512-2014-00004 · MDR key 4077252
Device
Product problems
- Deflation Problem
Patient
NI
- No Known Impact Or Consequence To Patient
Narrative
Description of Event or Problem
NARRATIVE: CASE WAS RECEIVED FROM A HOSPITAL FLUOROSCOPY AND CARDIOLOGY LEAD RADIOGRAPHER AT (B)(6). ON (B)(6) 2014 AND FORWARDED TO (B)(6). ON (B)(6) 2014. ON (B)(6) 2014, ADDITIONAL INFORMATION WAS RECEIVED FROM THE PRIMARY REPORTER DIRECTLY AT (B)(6). A HEALTH PROFESSIONAL REPORTS: ON (B)(6) 2014, THERE WERE 3 INCIDENTS OF BALLOON FAILING TO DEFLATE (NON LATEX MILLER AIR TIP, SYSTEM MODEL NO. 650012, LOT/SERIAL NO. (B)(4)) WHEN REMOVING THE CATHETER. CATHETERS WERE NOT KEPT BUT 1.5 BAGS LEFT OF THE SAME BATCH WHICH DEPT ARE NOW RELUCTANT TO USE. NO PATIENTS HAD ANY ADVERSE CONSEQUENCES AS A RESULT OF THE BALLOON NOT DEFLATING. THE RETURN OF ONE UNUSED SAMPLE OF THE SAME BATCH FOR INVESTIGATION HAS BEEN REQUESTED. OUTCOME: RECOVERED. FURTHER INFORMATION HAS BEEN REQUESTED. WORLDWIDE CASE ID: (B)(4).
Additional Manufacturer Narrative
COMPANY COMMENTS: A HEALTHCARE PROFESSIONAL REPORTED THAT IN 3 BARIUM ENEMA TESTS, THE BALLOON FAILED TO DEFLATE WHILE REMOVING THE CATHETER. GENERALLY, DURING THIS TYPE OF EXAMINATION, A LUBRICATED ENEMA TIP IS INSERTED INTO PATIENT'S RECTUM. THE TIP HAS A BALLOON THAT COULD BE INFLATED JUST ENOUGH TO KEEP BARIUM FROM LEAKING OUT (OF NOTE, NOT NECESSARILY THE BALLOON SHOULD BE COMPLETELY INFLATED). AS REPORTED IN LABELING, THE DEFLATION OF THE BALLOON SHOULD BE STARTED AFTER COMPLETION OF FLUOROSCOPY PHASE OF THE EXAM OR AFTER THE COLON IS COMPLETELY FILLED WITH BARIUM AND SHOULD BE COMPLETED BEFORE REMOVING THE ENEMA TIP. THIS APPROACH GUARANTEES GOOD IMAGES DURING THE EXAMINATION AND AVOIDS LESIONS IN EXTRACTING A FULLY INFLATED BALLOON. BASED ON THE ABOVE AND CONSIDERING THAT NO CLINICAL CONSEQUENCES WERE REPORTED IN THE 3 PATIENTS, THE MANUFACTURER ARGUES THAT IN THESE CASES THE BALLOON WAS AT LEAST PARTIALLY DEFLATED BEFORE REMOVING IT. IN FACT, THE REMOVAL OF A FULLY INFLATED BALLOON WOULD HAVE BEEN QUITE IMPOSSIBLE AND WOULD HAVE LED TO A DIFFICULT EXTRACTION MANEUVERS WITH TRAUMATIC LESIONS OF THE RECTUM OR ANUS. IN ANY CASE, SINCE THE INFORMATION ON MANUFACTURER'S HANDS IS VERY SCANTY, IT WAS DECIDED TO HAVE A CONSERVATIVE APPROACH AND TO REPORT THESE CASES.