PALL "LIPIPOR" TNA FILTER
Received Nov 16, 2018 · Event occurred Oct 18, 2018
Report 9680602-2018-00005 · MDR key 8080716
Device
Product problems
- Improper Flow or Infusion
- Improper Flow or Infusion
Patient
Not reported
- Hyperglycemia
- Hyperthermia
- Hypoglycemia
- Respiratory Distress
- Tachycardia
- Hyperglycemia
- Hyperthermia
- Hypoglycemia
- Respiratory Distress
- Tachycardia
Narrative
Additional Manufacturer Narrative
THE IMPLICATED FILTER WAS REQUESTED FOR EVALUATION, UNFORTUNATELY THE IMPLICATED FILTER WAS NOT AVAILABLE FOR RETURN AND A DIRECT EVALUATION WAS NOT POSSIBLE. A REVIEW OF OUR MANUFACTURING RECORDS WAS CONDUCTED AND HAS CONFIRMED THAT PRODUCT CODE TNA1E LOT # 18-839 WAS MANUFACTURED AND QUALITY CONTROL TESTED IN ACCORDANCE WITH OUR DOCUMENTED PROCEDURES AND MET ALL CRITERIA REQUIRED FOR RELEASE. NO ANOMALIES OR NON-CONFORMITIES WERE IDENTIFIED. A COMPLAINT DATABASE SEARCH WAS CONDUCTED ON THE ABOVE PART AND LOT NUMBER WHICH CONFIRMED NO OTHER OCCURRENCES OF THIS NATURE WERE NOTED. BASED ON THE INFORMATION PROVIDED AND THE DOCUMENTATION REVIEW, IT WAS DETERMINED THAT THE FILTER WAS UNLIKELY TO BE A CONTRIBUTING CAUSE OF THE REPORTED ISSUE. NO FURTHER ACTION IS PROPOSED AT THIS TIME. UNLESS SUBSTANTIALLY SIGNIFICANT INFORMATION BECOMES AVAILABLE, THIS CONSTITUTES A FINAL REPORT.
Additional Manufacturer Narrative
THE TNA1E FILTER ASSOCIATED WITH THIS INCIDENT WAS NOT RETAINED BY THE USER. THE INVESTIGATION IS UNDERWAY; CURRENTLY WE ARE AWAITING THE HOSPITAL TO CONFIRM ADDITIONAL OCCURRENCE DETAILS. OUR FINDINGS WILL BE "PULBLISHED", TARGET FOR COMPLETION JANUARY 4TH, 2019.
Description of Event or Problem
THE CUSTOMER REPORTED TO PALL THAT AIR WAS OBSERVED DOWNSTREAM OF A PALL LIPIPOR TNA FILTER (TNA1E), LOT# 18-839. IT WAS INDICATED THAT DURING ADMINISTRATION, IT WAS NOTED THAT THE TOTAL VOLUME OF THE PARENTERAL BAG (500ML) WAS DISTRIBUTED IN 6 HOURS, AS OPPOSED TO THE NORMAL DISTRIBUTION OF 200ML IN 14 HOURS. ON (B)(6) THE INFUSION LINE WAS DISCONNECTED FROM THE CHILD PATIENT. BEFORE THE SECOND RECONNECTION, THE NURSE SAW BUBBLES IN THE FILTER EXTENSION AND THEN IN THE FILTER. CLINICAL CONSEQUENCES OBSERVED: HYPERTHERMIA, TACHYCARDIA, RESPIRATORY DISTRESS, HYPERGLYCEMIA, THEN HYPOGLYCEMIA. ACTIONS UNDERTAKEN: CHANGE OF TUBING, FILTER, AND INFUSION PUMP. NOTE: IMPLICATED REORDER CODE TNA1E IS NOT REGISTERED AND SOLD IN THE US. ALL FDA INFORMATION BELOW RELATES TO A "LIKE" PRODUCT, REORDER CODE TNA1, WHICH IS REGISTERED FOR SALE IN THE US.