inforMED
MalfunctionFII

PRISMA

Received Jul 25, 2007 · Event occurred Jul 6, 2007

Report 898897 · MDR key 898897

Device

Generic name

Dialysis Machine, Crrt

Model number

PRISMA

Catalog number

*

Lot number

*

Product problems

  • Alarm, audible
  • Bubble(s)

Patient

75 YR

  • Cardiac Arrest
  • Improved patient condition
  • Resuscitation
  • Therapy/non-surgical treatment, aborted/stopped

Narrative

Description of Event or Problem

THE MACHINE WAS PRIMED AND CONNECTED TO THE PATIENT. WHEN THE CONTINUOUS VENOVENOUS HEMODIALYSIS (CVVHD) MACHINE WAS STARTED IT WAS ALARMING WITH MICRO AIR IN THE BLOOD AND NOTED A LOT OF AIR IN THE FILTER. COULD NOT TROUBLESHOOT. STOPPED THE MACHINE AND THE ACCESS LINE WAS FLUSHED AND CAPPED. THE PATIENT CODED SHORTLY AFTER THIS EVENT, BUT WAS RESUSCITATED SUCCESSFULLY.