inforMED
MalfunctionCBL

CARBOLIME

Received Jun 8, 2007 · Event occurred May 26, 2007

Report 1924066-2007-00006 · MDR key 863481

Device

Generic name

Co2 Absorbent

Model number

55-01-0006

Lot number

40617

Product problems

  • Material Discolored
  • Device Emits Odor

Patient

YR

  • Unknown (for use when the patient's condition is not known)

Narrative

Description of Event or Problem

IT WAS REPORTED THAT THE CARBOLIME HAD BEEN A SINGLE CANISTER ABSORBER FOR 1 WEEK. THEY HAD DONE ABOUT 10 HOURS OF SURGERY USING SEVOFLORANE AT A FLOW OF 1 LPM. THE CARBOLIME WAS A DARK COLOR AND SMELLED LIKE SOMETHING BURNT WHEN REMOVED.

Additional Manufacturer Narrative

A SINGLE CANISTER OF CARBOLIME IS GENERALLY GOOD FOR ABOUT 5.5 HOURS OF SURGERY. THEREFORE, AT 10 HOURS OF SURGERY, IT WAS USED ALMOST TWICE AS LONG AS IT SHOULD HAVE BEEN. CARBOLIME NEEDS TO BE CHANGED BASED ON THE COLOR CHANGE AS IT IS BEING USED.