The customer reported a patient was in cardiac arrest and they were trying to attach an emergency glass syringe to the microclave.The customer stated, ¿during a cardiac arrest on pediatric icu the above connectors did not allow injection of the emergency drugs and an alternative product was used to administer adrenaline¿.The customer reported that the injury was serious and there was a delay in resuscitation.Additionally, the customer stated they looked it up and now know that none of the microclave nfcs are compatible with prefilled glass syringes.The customer reported 5 microclaves were involved in the event.This report reflects the fourth of 5 devices.
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H10: no product samples were returned for investigation, however, a graphic was returned showing steps for using emergency glass syringes when using microclave connectors.An attempt was made by icu medical to have the facility provide sister samples for investigation but the customer responded that no samples were unable to be provided.No device history review (dhr) lot review was conducted because no lot number(s) was/were identified.Although the exact probable causes are unknown, use of glass tip/filled syringes are known to be dimensionally incompatible.Typically glass syringes have an internal diameter (id) of approximately 0.048¿.The clave/microclave requires a minimum of 0.062¿ id from the mating luer to accommodate the clave internal cannula.Luers that have an id smaller than 0.062¿, such as the glass syringes, may cause damage to the clave spike or obstruct flow.
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