SUPPORT ARM 177
Received Dec 4, 2014 · Event occurred Oct 28, 2014
Report 3008355164-2014-00303 · MDR key 4420294
Device
Manufacturer
Maquet Critical Care AbCatalog number
6481720
Product problems
- Mechanical Problem
- Unintended Movement
Patient
Not reported
- Extubate
Narrative
Description of Event or Problem
IT WAS REPORTED THA A PT ACCIDENTALLY WAS EXTUBATED DUE TO A SELF-LOWERING OF THE SUPPORT ARM, THAT HOLDS THE PT'S CIRCUIT, AT THE LEVEL OF JOINTS. THIS INCIDENT LEAD TO AN EMERGENCY RE-INTUBATION, WITH DIFFICULT CONDITIONS. THE RAPID RE-INTUBATION WAS COMPLICATED BY MASSIVE ASPIRATION WITH HEMATOSIS DEGRADATION, REQUIRING OPTIMIZATION OF MECHANICAL VENTILATION, SEDATION, CURARIZATION, AND SWITCHING TO VENTRAL DECUBITUS POSITION (SEVERAL SESSIONS OVER 4/5 DAYS). THE FINAL PT OUTCOME WAS NO INJURY. THE SUPPORT ARM JOINTS WERE TIGHTENED WHICH SOLVED THE PROBLEM AND THE SUPPORT ARM WAS PUT BACK IN USE. (B)(4). MFR REF # 8010042-2014-00549.