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It was reported that the foley catheter balloon had burst.A patient with delirium connected their own oxygen tube to the inflation valve while a foley catheter was in place.After that, hematuria due to urethral injury and balloon burst were confirmed.The event occurred days after the placement.The balloon rupture or tear observed on the foley catheter.It was unknown what medical intervention was provided.As per additional information received on 03aug2023, stated that the situation was that the patient called the nurse at 23:30 on the day and complained of pain in the lower abdomen.When the nurse checked, the oxygen cannula and oxygen extension tube were disconnected, and the oxygen extension tube connected to the central pipe was connected to the valve part (sterilized water injection part) of the indwelling bladder catheter.The nurse immediately disconnected the oxygen extension tube from the valve, and tried to suck the patient from the valve using a syringe, but neither water nor air could be drawn.When the catheter was removed, a breakage of approximately 0.5 x 1.4 cm in the balloon portion was observed.After that, hematuria occurred although spontaneous urination occurred.The patient was with cognitive decline.The oxygen flow rate was 1 l/min.It was unknown how long it was disconnected.The catheter was fixed to the thigh, but it was peeled off.On the day of treatment, the nurse would remove the catheter and check for damage.The user reported it to the attending physician and received instructions for referral to a urology department the next day.Hematuria was also reported, follow-up observation, and an additional urine test the next morning was instructed.The next day, they were referred to a urologist, and had an examination by a urologist in the morning.There was a medical report stating that since the patient was in a restless state, bladder irrigation and cystoscopy should be performed after the patient had calmed down.Around 12:00, the indwelling bladder catheter was inserted again by a urologist.Bladder washing by a urologist, no exacerbation of hematuria, and no ruptured fragments were observed.A cystoscopy was scheduled once the condition had stabilized.As per follow-up information received from ibc on 04aug2023, stated that it was not reported from the customer whether cystoscopy was performed.
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The reported event was confirmed ¿ cause unknown.The product had caused the reported failure.Based on the attached photo, a catheter with ruptured balloon was observed on the sample.However, the exact cause of how and when the problem occurred could not be determined.A potential root cause could be user related (example: contact with sharp object)/ exposure to petrolatum based products/ mechanical failure/operator error).A dhr review is not required as the lot number is unknown.The instructions for use were found adequate and states the following: warnings: 1.Method for use: (1) do not inflate the balloon in the urethra.The urethra may be injured.(2) do not pull the catheter hard.The bladder/urethra may be injured.2.Applicable patients: patients with delirium who might pull out catheter [when patient tugs at catheter unconsciously, the bladder and urethra may be damaged.] [contraindications] 1.Method for use: (1) do not reuse.(2) do not re-sterilize.(3) this device contains 10% povidone-iodine.For patients with past history of allergic hypersensitivity to povidone-iodine or iodine, consider using alternative disinfectants.(4) be careful that the catheter is not exposed to ointments, contrast medium or oil-based lubricants (including vegetable oils such as olive oil, mineral oils such as white petrolatum and animal oils).[they may damage the device and may burst balloon.] (5) do not hold the device with forceps, etc.Avoid contact with any blades or sharp-edged instruments.[catheter damage may cause balloon rupture and accidental balloon removal or failure to deflate or remove the balloon.] 2.Applicable patients: (1) patients who are or have been allergic to natural rubber latex.(2) patients with known allergy to silver coated catheter.[shape, configuration and principles] bard® i.C.Silver foley tray b consists of a balloon catheter, urine-collecting bag for closed drainage system, syringe prefilled with sterile water, water-soluble lubricant, antiseptic solution, tweezers, waterproof sheet, gauze pads, cotton balls, vinyl gloves and statlock® foley.There are several types of closed drainage bags.The bag and statlock® foley included in the tray will depend on the product.Material: balloon catheter: natural rubber latex; silver coating.This product is made with bacti-guard® silver alloy coating.Sizes of catheters: available in sizes 8 to 24 every 2fr.1.Foley catheter.2.Accessories.Closed drainage bag.(the illustration shows one example of typical configurations.) syringe prefilled with sterile water.Water soluble lubricant.Antiseptics: bard® 10% povidone-iodine solution.Tweezers.Gauze pads.Waterproof sheet.Cotton balls.Gloves.Statlock® foley.[intended use & effect- efficacy] the device is a tray kit product that is used for the purpose of urinary drainage and combines a disposable catheter designed to be placed in the bladder, and a urine drainage bag.[directions for use] 1.Method of use: the device is intended for single use only and is not reusable.(1) to secure a sterile field for the procedure, spread a clean wrapping paper.(2) place waterproof sheet beneath patient¿s buttocks.(fig.1) (3) put on sterile gloves.Open tray and place it on the wrapping paper.(fig.2) (4) cleanse the area around the external urethral meatus with the cotton balls immersed in the antiseptics.(fig.3) (5) lubricate the distal end of the catheter with water-soluble lubricant packaged in the tray.(fig.4) (6) insert catheter into the urethral meatus, and advance it until the balloon enters the bladder and urine flows out through the catheter.Using a syringe packaged in the tray, infuse the specified volume of sterile water into the inflation lumen to inflate the balloon.(fig.5) (7) pull catheter to seat the balloon at the level of the bladder neck and secure placement.(8) keep the drainage bag below the bladder level without touching the floor.(fig.6) (9) secure drainage tube to bed sheet with clip to ensure that there is neither twist nor kink in the tube.(fig.7) (10) to deflate balloon and remove catheter, insert a luer tip (needleless) syringe in the inflation valve to allow the water drain spontaneously.After balloon deflation, withdraw the catheter while confirming that no resistance is encountered.Direction for use bard® ez-lok® sampling port: 1) occlude drainage tubing a minimum of 10 cm below the sampling port by kinking the tubing until urine fills the tubing up to near (slightly above) the sampling port.2) swab surface of site with antiseptic wipe.3) using aseptic technique, position the needle-less syringe (slip-tip type or luer-lock type) in the center of the sampling port.The syringe should be held perpendicular to the surface of the sampling port.Press the syringe and twist to lock the syringe onto the sampling port.(fig.8) 4) aspirate desired volume of urine.After sampling, detach the syringe.Ensure that the rubber stem of the sampling port has returned to its original position.5) unkink tubing.How to disconnect catheter from tubing: catheter is pre-connected to ez-lok, and the connecting part is covered with red seal (tamper-evident seal).Remove the seal by grasping the tab at the end of the seal and pulling along perforations, and then disconnect the catheter and the tubing using aseptic technique.(fig.9) 2.Precautions for use: (1) when resistance is encountered in inserting catheter, stop the procedure and remove the catheter.(2) when deflating balloon, do not aspirate with a syringe.[the inflation lumen for balloon deflation may be occluded by negative pressure, and as a result the catheter cannot be removed.] (3) no substance except sterile water should be used to inflate the balloon.[if contrast medium is used, balloon may burst.If normal saline is used, crystallized salt may occlude the inflation lumen to prevent deflation of the balloon.If air is used, air may escape to cause inadvertent deflation of the balloon so that the catheter may come out prematurely.] (4) do not wipe catheter surface with organic solvents such as alcohol.(5) do not aspirate urine through drainage funnel wall.(6) since movement of the body, etc.May twist or bend catheter to cause occlusion, care should be taken to fix the catheter securely.(7) when urinary flow cannot be noted, confirm that the catheter is neither occluded nor broken.(8) avoid force on the connecting parts as they may be accidentally disconnected due to the weight of the drainage bag etc.And may cause urine spill.(9) do not pull or twist the outlet tube.Also, do not squeeze the drainage bag.[the joint of the drainage bag and the outlet tube may be damaged and urine leakage may occur.] (10) when disposing of urine, observe the following; 1) remove the outlet tube from the housing of the urine drainage bag.2) lift the green lever to open with holding the outlet tube.Be careful not to pull the outlet tube when lifting the green lever.3) when disposal of urine is completed, close the green lever and put the outlet tube into the housing.(11) when using statlock® foley, observe the following: 1) do not use the statlock® device where loss of adherence could occur, such as with a confused patient, unattended access device, diaphoretic or nonadherent skin.2) minimize catheter manipulation during statlock® stabilization device application and removal.3) do not use the statlock® device for patients showing allergic reaction to tape or adhesive.4) conduct skin assessment prior to application and repeat daily per facility protocol.5) the statlock® device should be assessed daily and changed when clinically, indicated, at least every seven days.6) after placing the statlock® device, allow to dry completely (10-15 seconds) due to alcohol included in skin protectant.7) use alcohol pads when removal.Do not pull or force pad to remove.[precautions] 1.Precautions for use (exercise caution when using the device in the following patients).(1) exercise caution when using the device in patients with high urinary calcium levels as encrustation on the balloon surface, catheter occlusion or damage may occur.2.Important precautions: (1) when catheter is inadvertently removed, inspect the balloon and shaft of catheter for rupture, defect, etc.Before inserting a new catheter.(2) when any part of the balloon and/or the catheter is missing, consider removing them using a cystoscope.(3) when it is difficult to remove catheter by deflating the balloon, take appropriate measures according to the section ¿troubleshooting¿.Troubleshooting: when it is difficult to remove catheter by deflating the balloon (expressed as ¿removal-difficult case¿ hereinafter), take appropriate measures according to the following procedures.The following two methods are available for removal-difficult cases.A.Non-rupture method (sterile water is withdrawn without bursting the balloon.) b.Balloon-rupture method.With balloon-rupture method, fragments of the ruptured balloon may remain in the bladder.Therefore, try non-rupture method first.A.Non-rupture method: 1) attach luer tip syringe to the inflation valve.Inject an additional amount of sterile water into the inflation lumen and pump the plunger.2) if situation wouldn't be improved with 1), sever the inflation funnel of valve.(fig.10) 3) if situation wouldn¿t be improved with 2), sever the catheter shaft while holding it with forceps so that the distal segment may not be drawn into the urethra.(fig.11) 4) if situation wouldn't be improved with 3), insert a needle into the inflation lumen and pump the plunger.(fig.12) 5) if situation wouldn't be improved with 4), insert a fine steel wire through the inflation lumen of catheter.(fig.13) b.Balloon-rupture method: 1) inject 100-200ml/cc of saline solution warmed to body temperature into the bladder through the drainage lumen, and then inject a large amount of water or 10-15 ml/cc of mineral oil into the balloon through the inflation lumen with a needle to induce rupture.After rupture of the balloon, irrigate the bladder.(fig.14) 2) if situation wouldn't be improved with 1), attempt following procedures.A) under the radioscopic observation, infuse a contrast medium into the bladder, and burst the balloon by suprapubic puncture of the bladder.(fig.15) b) in male patients, burst the balloon by puncture with a needle from the perineal (or suprapubic) region or through the rectum under ultrasonographic guidance.(fig.16) c) in female patients, burst the balloon by insertion of a needle along the urethra.(fig.17) 3.Malfunction and adverse events: 1) malfunction: catheter kinking, damage, rupture.Difficulty or failure to remove the device.Occlusion of catheter inner lumens.Encrustation.Accidental removal of the device due to leakage of sterile water or balloon rupture device damage due to inappropriate use.2) adverse events: urinary-tract infection.Hemorrhage, hematuria.Allergy reaction to the device.Calculus formation.Edema.Pain.Discomfort.Injury of bladder or urethral.Urethritis, urinary incontinence.Retained balloon fragments.Storage method and expiration date: 1.Storage: store in a dry, cool place away from heat, moisture, and direct sunlight.2.Expiration date: indicated on the direct package and the outer box.H11: section a through f - the information provided by bd represents all the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.H3 other text : the actual/suspected device was inspected.
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