SORIN GROUP ITALIA SRL LILLIPUT PH.I.S.I.O. INFANT HOLLOW FIBRE OXYGENATOR D902; OXYGENATOR, CARDIOPULMONARY BYPASS
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Model Number D902 PH.I.S.I.O. |
Device Problem
Blocked Connection (2888)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Type
malfunction
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Manufacturer Narrative
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Patient information were not provided.Date of event is unknown sorin group (b)(6) manufactures the d902 dideco lilliput phisio oxygenator.The incident occurred in (b)(6).Since the oxygenator is blood contaminated, the involved device has not been requested for return to sorin group (b)(6) for investigation if any additional information pertinent to the reported event is received, it will be provided in a supplemental report.Blood contaminated.
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Event Description
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Sorin group italia has received a report that, during a procedure, the manifold line of the d902 dideco lilliput phisio oxygenator was not working.Medical team elected to change-out the oxygenator.There is no report of any patient injury.
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Manufacturer Narrative
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Review of complaints database revealed no other similar cases notified for batch concerned from the market.Livanova started a follow-up activity with submitter to find out specific phase when change-out of the unit was conducted and its duration.However, no reply was given.Considering the intended use of this port (i.E.Monitoring the gas exchange performances), it is reasonable to assume that change-out of the unit was conducted in the early phase of surgery when taking the first arterial blood sample (failed attempt).Based on results of investigation of previous similar events, the most probable root cause of the issue was a damaged valve insert body.The valve insert regulates the valve opening.If the valve insert is damaged, (i.E.Due to handling when manually positioned on silicone membrane valve in manufacturing line or due to excessive screwing force of male luer lock cap applied during assembly phase), the valve cannot be opened and no flow is possible a non-conformity report has been opened to investigate the assembly of the one-way valve.The risk associated is in the acceptable region.At the moment no corrective action is deemed necessary.Livanova will keep monitoring the market.
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Event Description
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See initial report.
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Search Alerts/Recalls
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