ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V. 32" (81 CM) APPX 6.3 ML, 15 DROP ADMIN SET W/0.2 MICRON FILTER, ROTATING LUER; STOPCOCK, I.V. SET
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Catalog Number B30183 |
Device Problem
Air/Gas in Device (4062)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 08/08/2023 |
Event Type
malfunction
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Manufacturer Narrative
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The complete d1 - brand name is 32" (81 cm) appx 6.3 ml, 15 drop admin set w/0.2 micron filter, rotating luer w/filter cap, bag hanger.The device was returned for evaluation.The investigation is pending.
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Event Description
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The event involved a 32" (81 cm) appx 6.3 ml, 15 drop admin set w/0.2 micron filter, rotating luer w/filter cap, bag hanger where an air in line towards the end of durvalumab infusion was reported at 12:59.The infusion rate was 280 ml/hr.There was patient involvement and unknown patient harm reported.
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Manufacturer Narrative
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One used sample list #b30183 connected with spiros, an used bd phaseal and a fresenius kabi 0.9% sodium chloride injection usp freeflex 500 ml intravenous bag with durvalumab were returned for evaluation.The inlet and outlet filters appeared to be wetted out.No additional damage or anomaly was observed.The set was primed and purged as per procedure and a leaks coming from the outlet filter vent was confirmed.No additional leaks or air in line were observed.Complaint of product incorporate / allows air passage cannot be confirmed, due to no air after purge the line was confirmed.Small bubbles trapped inside the filter were observed, however, that's an indication of normal functionality of the filter.Only a leak coming from outlet filters was confirmed.The probable cause is typical due to a temporary or complete loss of hydrophobic properties of the filter vent material due to an infusate interaction during use.The lot history was reviewed, no nonconformities were identified that may have contributed to the reported complaint.
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