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| Catalog Number 50000000 |
| Device Problem
Power Problem (3010)
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| Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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| Event Date 03/01/2024 |
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Event Type
malfunction
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Manufacturer Narrative
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The investigation is still in progress.Once the investigation is complete a supplemental report will be filed.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.
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Event Description
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It was reported that the during 1st call from nurse stated they had a patient in normothermia.The patient had been at target 37c.The patient temperature dropped to 32.778°c and the water temperature (wt) was only 23.889°c.Nurse stated they ended up changing to a new device because it did not seem to be warming the water.Nurse stated the water temperature on the new device was still only 24.444°c.Currently had therapy stopped.Confirmed they had four pads connected.Discussed because patient was now below target, the device will begin to control rewarm back to the targeted temperature (tt).Explained the water temperature (wt) may not be super warm to prevent overshoot, consider heat generation.Recommended any counter warming per their protocol, nurse confirmed they had a bair hugger on and will add warm blankets.Nurse stated the control box in normothermia shows targeted temperature (tt) 37°c and rewarm at a rate of 32.222°c.Had nurse select new therapy under hypothermia.Set rewarms from to current patient temperature 34.4c at a rate of 0.25c/hour per their protocol, to targeted temperature (tt) was 37c.Had nurse start rewarming.Diagnostics were outlet monitor temperature (t1) was 25.2c, outlet control temperature (t2) was 25.2c, inlet temperature (t3) was 25.7c, chiller temperature (t4) was 4.7c, water flow rate (wfr) was 2 l/min, inlet pressure (ip) was -7psi, circulation pump command (cpc) was 49%, mixing pump command (mpc) was 0%, heater command (hc) was 0%, water reservoir level (wrl) was 5, system hours were 15,265, pump hours were 14,166.Biomed at bedside to help troubleshoot.Walked biomed through placing device in manual control set to 40c to confirm water was heating, once started, the device shut off.Confirmed device was plugged into wall outlet.Biomed stated the first device they checked in manual control, and it heated to 40c without issues.Suggested to bring device to nurse to restart therapy on and take this one to biomed.Walked nurse through emptying pads.Nurse stated once they get the first device back, they would call back.Called nurse back at 12:02 pm, nurse stated the providers think it was patient related, providers have decided to discontinue use of the device.Informed nurse they would pass this along to the tm/cm to assist with downloading the case date.2nd call received biomed had device that was just sent down to shop.Only information they had was that the patient temperature (pt) was 97 and water temperature (wt) was in the 70s (not aware of tt).They have already replaced the device and they would like help troubleshooting.
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Manufacturer Narrative
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The reported issue was confirmed.The root cause of the reported issue could not be identified.Although a root cause could not be definitively identified, a potential root cause for this type of failure could be power supply failure.However, there was insufficient information to confirm this potential root cause.A dhr review is not required as the serial number is unknown.The instructions for use were found adequate and state the following: ¿the arctic sun¿ temperature management system is a thermal regulating system, indicated for monitoring and controlling patient temperature in adult and pediatric patients of all ages.Warnings and cautions warnings ¿ do not use the arctic sun¿ temperature management system in the presence of flammable agents because an explosion and/or fire may result.¿ do not use high frequency surgical instruments or endocardial catheters while the arctic sun¿ temperature management system is in use.¿ there is a risk of electrical shock and hazardous moving parts.There are no user serviceable parts inside.Do not remove covers.Refer servicing to qualified personnel.¿ power cord has a hospital grade plug.Grounding reliability can only be achieved when connected to an equivalent receptacle marked ¿hospital use¿ or ¿hospital grade¿.¿ when using the arctic sun¿ temperature management system, note that all other thermal conductive systems, such as water blankets and water gels, in use while warming or cooling with the arctic sun¿ temperature management system may actually alter or interfere with patient temperature control.¿ do not place arcticgel¿ pads over transdermal medication patches as warming can increase drug delivery, resulting in possible harm to the patient.¿ the arctic sun¿ temperature management system is not intended for use in the operating room environment.¿ medivance supplies temperature simulators (fixed value resistors) for testing, training and demonstration purposes.Never use this device, or other method, to circumvent the normal patient temperature feedback control when the system is connected to the patient.Doing so exposes the patient to the hazards associated with severe hypo- or hyper-thermia.Cautions ¿ this product is to be used by or under the supervision of trained, qualified medical personnel.¿ federal law (usa) restricts this device to sale, by or on the order of a physician.¿ use only sterile water.The use of other fluids will damage the arctic sun¿ temperature management system.¿ when moving the arctic sun¿ temperature management system always use the handle to lift the controller over an obstacle to avoid over balancing.¿ the patient¿s bed surface should be located between 30 and 60 inches (75 cm and 150 cm) above the floor to ensure proper flow and minimize risk of leaks.¿ the clinician is responsible to determine the appropriateness of custom parameters.When the system is powered off, all changes to parameters will revert to the default unless the new settings have been saved as new defaults in the advanced setup screen.For small patients (=30 kg) it is recommended to use the following settings: water temperature high limit =40°c (104°f); water temperature low limit =10°c (50°f); control strategy = 2.It is recommended to use the patient temperature high and patient temperature low alert settings.¿ manual control is not recommended for patient temperature management.The operator is advised to use the automatic therapy modes (e.G.Control, patient, cooling, rewarming) for automatic patient temperature monitoring and control.¿ the arctic sun¿ temperature management system will monitor and control patient core temperature based on the temperature probe attached to the system.The clinician is responsible for correctly placing the temperature probe and verifying the accuracy and placement of the patient probe at the start of the procedure.¿ medivance recommends measuring patient temperature from a second site to verify patient temperature.Medivance recommends the use of a second patient temperature probe connected to the arctic sun¿ temperature management system temperature 2 input as it provides continuous monitoring and safety alarm features.Alternatively, patient temperature may be verified periodically with independent instrumentation.¿ the displayed temperature graph is for general information purposes only and is not intended to replace standard medical record documentation for use in therapy decisions.¿ patient temperature will not be controlled and alarms are not enabled in stop mode.Patient temperature may increase or decrease with the arctic sun¿ temperature management system in stop mode.¿ carefully observe the system for air leaks before and during use.If the pads fail to prime or a significant continuous air leak is observed in the pad return line, check connections.If needed, replace the leaking pad.Leakage may result in lower flow rates and potentially decrease the performance of the system.¿ the arctic sun¿ temperature management system is for use only with the arcticgel¿ pads.¿ the arcticgel¿ pads are only for use with the arctic sun¿ temperature management systems.¿ the arcticgel¿ pads are non-sterile for single patient use.Do not reprocess or sterilize.If used in a sterile environment, pads should be placed according to the physician¿s request, either prior to the sterile preparation or sterile draping.Arcticgel¿ pads should not be placed on a sterile field.¿ use pads immediately after opening.Do not store pads once the kit has been opened.¿ do not place arcticgel¿ pads on skin that has signs of ulceration, burns, hives, or rash.¿ while there are no known allergies to hydrogel materials, caution should be exercised with any patient who has a history of skin allergies or sensitivities.¿ do not allow circulating water to contaminate the sterile field when patient lines are disconnected.¿ the water content of the hydrogel affects the pad¿s adhesion to the skin and conductivity, and therefore, the efficiency of controlling patient temperature.Periodically check that pads remain moist and adherent.Replace pads when the hydrogel no longer uniformly adheres to the skin.Replacing pads at least every 5 days is recommended.¿ do not puncture the arcticgel¿ pads with sharp objects.Punctures will result in air entering the fluid pathway and may reduce performance.¿ if accessible, examine the patient¿s skin under the arcticgel¿ pads often, especially those at higher risk of skin injury.Skin injury may occur as a cumulative result of pressure, time and temperature.Possible skin injuries include bruising, tearing, skin ulcerations, blistering, and necrosis.Do not place bean bag or other firm positioning devices under the arcticgel¿ pads.Do not place positioning devices under the pad manifolds or patient lines.¿ the rate of temperature change and potentially the final achievable patient temperature is affected by many factors.Treatment application, monitoring and results are the responsibility of the attending physician.If the patient does not reach target temperature in a reasonable time or the patient is not able to be maintained at the target temperature, the skin may be exposed to low or high water temperatures for an extended period of time which may increase the risk for skin injury.Ensure that pad sizing/coverage and custom parameter settings are correct for the patient and treatment goals, refer to the arcticgel¿ pad instructions for use for the appropriate flow rate.For patient cooling, ensure environmental factors such as excessively hot rooms, heat lamps, and heated nebulizers are eliminated and patient shivering is controlled.Otherwise, consider increasing minimum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.For patient warming, consider decreasing maximum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.¿ due to underlying medical or physiological conditions, some patients are more susceptible to skin damage from pressure and heat or cold.Patients at risk include those with poor tissue perfusion or poor skin integrity due to diabetes, peripheral vascular disease, poor nutritional status, steroid use or high dose vasopressor therapy.If warranted, use pressure relieving or pressure reducing devices under the patient to protect from skin injury.¿ do not allow urine, antibacterial solutions or other agents to pool underneath the arcticgel¿ pads.Urine and antibacterial agents can absorb into the pad hydrogel and cause chemical injury and loss of pad adhesion.Replace pads immediately if these fluids come into contact with the hydrogel.¿ do not place arcticgel¿ pads over an electrosurgical grounding pad.The combination of heat sources may result in skin burns.¿ if needed, place defibrillation pads between the arcticgel¿ pads and the patient¿s skin.¿ carefully remove arcticgel¿ pads from the patient¿s skin at the completion of use.Discard used arcticgel¿ pads in accordance with hospital procedures for medical waste.¿ the usb data port is to be used only with a standalone usb flash drive.Do not connect to another mains powered device during patient treatment.¿ users should not use cleaning or decontamination methods different from those recommended by the manufacturer without first checking with the manufacturer that the proposed methods will not damage the equipment.Do not use bleach (sodium hypochlorite) as it may damage the system.¿ medivance will not be responsible for patient safety or equipment performance if the procedures to operate, maintain, modify or service the medivance arctic sun¿ temperature management system are other than those specified by medivance.Anyone performing the procedures must be appropriately trained and qualified.¿ 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 device was not returned.
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Event Description
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It was reported that the during 1st call from nurse stated they had a patient in normothermia.The patient had been at target 37c.The patient temperature dropped to 32.778°c and the water temperature (wt) was only 23.889°c.Nurse stated they ended up changing to a new device because it did not seem to be warming the water.Nurse stated the water temperature on the new device was still only 24.444°c.Currently had therapy stopped.Confirmed they had four pads connected.Discussed because patient was now below target, the device will begin to control rewarm back to the targeted temperature (tt).Explained the water temperature (wt) may not be super warm to prevent overshoot, consider heat generation.Recommended any counter warming per their protocol, nurse confirmed they had a bair hugger on and will add warm blankets.Nurse stated the control box in normothermia shows targeted temperature (tt) 37°c and rewarm at a rate of 32.222°c.Had nurse select new therapy under hypothermia.Set rewarms from to current patient temperature 34.4c at a rate of 0.25c/hour per their protocol, to targeted temperature (tt) was 37c.Had nurse start rewarming.Diagnostics were outlet monitor temperature (t1) was 25.2c, outlet control temperature (t2) was 25.2c, inlet temperature (t3) was 25.7c, chiller temperature (t4) was 4.7c, water flow rate (wfr) was 2 l/min, inlet pressure (ip) was -7psi, circulation pump command (cpc) was 49%, mixing pump command (mpc) was 0%, heater command (hc) was 0%, water reservoir level (wrl) was 5, system hours were 15,265, pump hours were 14,166.Biomed at bedside to help troubleshoot.Walked biomed through placing device in manual control set to 40c to confirm water was heating, once started, the device shut off.Confirmed device was plugged into wall outlet.Biomed stated the first device they checked in manual control, and it heated to 40c without issues.Suggested to bring device to nurse to restart therapy on and take this one to biomed.Walked nurse through emptying pads.Nurse stated once they get the first device back, they would call back.Called nurse back at 12:02 pm, nurse stated the providers think it was patient related, providers have decided to discontinue use of the device.Informed nurse they would pass this along to the tm/cm to assist with downloading the case date.2nd call received biomed had device that was just sent down to shop.Only information they had was that the patient temperature (pt) was 97 and water temperature (wt) was in the 70s (not aware of tt).They have already replaced the device and they would like help troubleshooting.
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Search Alerts/Recalls
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