inforMED
MalfunctionFIL

FRESENIUS DIALYSIS DELIVERY SYSTEM

Received Jun 25, 2003 · Event occurred May 27, 2003

Report 2937457-2003-00019 · MDR key 469190

Device

Generic name

Hemodialysis Machine

Model number

2008K

Catalog number

NA

Lot number

NA

Product problems

  • Device Alarm System
  • Leak/Splash
  • Replace

Patient

UNKNOWN

  • Therapy/non-surgical treatment, aborted/stopped
  • Blood Loss

Narrative

Description of Event or Problem

THERE WAS AN EXTERNAL AND INTERNAL DIALYZER BLOOD LEAK A FEW MINUTES AFTER HEMODIALYSIS TREATMENT WAS STARTED. BLOOD ON THE FLOOR AND WAS ESTIMATED TO BE AROUND 300 CC. BLOOD WAS ALSO VISIBLE IN THE DIALYSATE LINES AND THERE WAS NO MACHINE ALARM. THE EXTRACORPOREAL CIRCUIT WAS DISCARDED AND TREATMENT WAS RESUMED ON ANOTHER MACHINE. THERE WAS NO PT COMPLICATION AND NO BLOOD TRANSFUSION WAS NECESSARY.