MAUDE Adverse Event Report: ERBE ELEKTROMEDIZIN GMBH ERBE APC 2; ARGON PLASMA COAGULATOR

Model Number APC 2

Device Problem Appropriate Term/Code Not Available (3191)

Patient Problem Bowel Perforation (2668)

Event Date 05/05/2023

Event Type  Injury  

Event Description

It was reported that an erbe system, argon plasma coagulator (apc)/electrosurgical unit [esu/generator, model vio 200 d, part number (p/n) 10140-200, serial number (b)(6)] system was involved in a patient incident.The apc/esu system was used to address angiodysplasia in the colon.No information was provided regarding other equipment or accessories used in the procedure.The apc/esu system settings were pulsedapc mode with the effect manually adjusted from effect 2 to effect 1 (note: the involved medical staff believed that the adjustment would reduce the output power.).Also, it was reported that the patient's abdominal wall twitched during activation.After the argon plasma application, a secondary or delayed perforation occurred.That is, a 2 mm diameter perforation was detected a day after the interventional work.Therefore, another colonoscopy was performed to close the hole.Then, the patient was treated with antibiotics and had to stay in the hospital.

Manufacturer Narrative

The apc/esu system was returned and thoroughly inspected/tested.A technical safety check was performed on each unit.This included an electrical safety check, a functional check of each of the equipment's features, and a power output check.Also, the gas flow rates were measured and found to be within their acceptable ranges for the apc.All features were/are functioning properly within specifications on both devices.The system's chronological data at the time of the procedure revealed that the settings were pulsedapc mode, effect 1 at 30 watts and 20 watts.Activations were short in duration.Also, there were no notifications or error messages during the interventional work.In addition, no anomalies were found in the device history records (dhrs) for the apc and esu.In conclusion, no erbe equipment problem was found that would have caused or attributed to the event.Most likely, there were many factors involved in the reported incident (i.E., the patient's age, etc.).However, the setting change of the effect was probably not ideal for procedure.That is, the effect change from 2 to 1 intensified each pulse as well as lengthened the time between the pulses.Additionally, this change increased the possibility of neuromuscular stimulation (nms) [i.E., the observed twitching of the patient's abdominal wall during activation].Nevertheless, upon the interventional work, the remaining tissue of the bowl did not stay intact which resulted in the perforation.Finally, no conclusive determination could be made as to the cause of the incident.No trends have been identified.Erbe usa, inc.Is now closing the file on this event.

• Brand Name: ERBE APC 2
• Type of Device: ARGON PLASMA COAGULATOR
• Manufacturer (Section D): ERBE ELEKTROMEDIZIN GMBH; waldhornlestrasse 17; tubingen, germany 72072 ; GM 72072
• Manufacturer (Section G): ERBE ELEKTROMEDIZIN GMBH; waldhornlestrasse 17; tubingen, germany 72072 ; GM 72072
• Manufacturer Contact: john tartal ; 2225 northwest parkway; marietta, GA 30067-8764 ; 7709554400
• MDR Report Key: 16973154
• MDR Text Key: 315675598
• Report Number: 9610614-2023-00029
• Device Sequence Number: 1
• Product Code: GEI
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: K024047
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 05/22/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 05/22/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: APC 2
• Device Catalogue Number: 10134-000
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/11/2023
• Date Manufacturer Received: 05/08/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 12/15/2009
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention; Hospitalization
• Patient Age: 86 YR
• Patient Sex: Male
• Patient Weight: 76 KG