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| Catalog Number 63001 |
| Device Problems
Failure to Calibrate (2440); Calibration Problem (2890)
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| Patient Problems
Awareness during Anaesthesia (1707); Overdose (1988); Respiratory Distress (2045); Ventilator Dependent (2395)
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| Event Date 11/21/2016 |
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Event Type
Injury
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Event Description
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A medical science liaison reported on 01-dec-2016 that an elderly male patient of unknown age experienced being under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating after administration of photofrin (porfimer sodium) for an unknown indication and co-suspect device's modulight 630 pdt laser (serial number (b)(4)) and modulight 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.The patient's significant past medical history included a bad heart.No other information was provided regarding the patient's medical history, concurrent conditions, or other concomitant medications.On an unknown date, the patient started photofrin (porfimer sodium) for an unknown indication and co-suspect device's modulight 630 pdt laser (serial number (b)(4)) and modulight 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.On (b)(6) 2016, the patient experienced under anesthesia longer than he should have because the fibers were not calibrating.The patient ended up having to go to the intensive care unit on the ventilator after the pdt case on (b)(6) 2016.Both lasers successfully calibrated (with multiple attempts) the dcyl 210, 710, 725, 750, however, both lasers failed calibration (with multiple attempts) for the dcyl 225, 250.Both lasers also put out too much power (see relevant laboratory tests), with laser (serial number (b)(4)) putting out the highest power at a not acceptable level.The reporter stated that some of the fibers failed.The cuvette in the lasers was switched out for a different cuvette (a cleaner appearing cuvette), the first laser (serial number (b)(4)) passed calibration with dcyl 225 and 250, and put out more accurate power (dcyl 710 power output went from 129% to 106% with new cuvette).The same new cuvette was placed into the second laser (serial number (b)(4)), it passed calibration dcyl 225, but still failed calibration dcyl 250.The outcome of under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating is unknown.The reporter did not provide their assessment of the causal relationship of the event to photofrin (porfimer sodium) use.Additional information was received on 10-dec-2016 from a company representative.The following additional information was obtained.The patient was confirmed to have recovered and was released from the icu.
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Manufacturer Narrative
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A medical science liaison reported on 01-dec-2016 that an elderly male patient of unknown age experienced being under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating after administration of photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) and photofrin 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.The patient's significant past medical history included a bad heart.No other information was provided regarding the patient's medical history, concurrent conditions, or other concomitant medications.On an unknown date, the patient started photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) and photofrin 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.On (b)(6) 2016, the patient experienced under anesthesia longer than he should have because the fibers were not calibrating.The patient ended up having to go to the intensive care unit on the ventilator after the pdt case on (b)(6) 2016.Both lasers successfully calibrated (with multiple attempts) the dcyl 210, 710, 725, 750, however, both lasers failed calibration (with multiple attempts) for the dcyl 225, 250.Both lasers also put out too much power (see relevant laboratory tests), with laser (serial number (b)(4)) putting out the highest power at a not acceptable level.The reporter stated that some of the fibers failed.The cuvette in the lasers was switched out for a different cuvette (a cleaner appearing cuvette), the first laser (serial number (b)(4)) passed calibration with dcyl 225 and 250, and put out more accurate power (dcyl 710 power output went from 129% to 106% with new cuvette).The same new cuvette was placed into the second laser (serial number (b)(4)), it passed calibration dcyl 225, but still failed calibration dcyl 250.The outcome of under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating is unknown.The reporter did not provide their assessment of the causal relationship of the event to photofrin (porfimer sodium) use.Additional information was received on 10-dec-2016 from a company representative.The following additional information was obtained.The patient was confirmed to have recovered and was released from the icu.Correction report: a physician reported to the medical science liaison on 01-dec-2016 that an elderly male patient of unknown age experienced being under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating after administration of photofrin (portimer sodium) for esophageal cancer and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) for the esophageal pdt treatment.This is 1 of 2 reports received from the same reporter [(b)(4) (3010119152-2017-00001)].The patient's significant past medical history included a bad heart.No other information was provided regarding the patient's medical history, concurrent conditions, or other concomitant medications.On an unknown date, the patient started photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) for the esophageal pdt treatment.On (b)(6) 2016, the patient experienced under anesthesia longer than he should have because the fibers were not calibrating.The patient ended up having to go to the intensive care unit on the ventilator after the pdt case on (b)(6) 2016.Two lasers ((b)(4)) were successfully calibrated (with multiple attempts) the dcyl 210, 710, 725, 750, however, both lasers failed calibration (with multiple attempts) for the dcyl 225, 250.Both lasers also put out too much power (see relevant laboratory tests), with laser (serial number (b)(4)) putting out the highest power at a not acceptable level.The reporter stated that some of the fibers failed.The cuvette in the lasers was switched out for a different cuvette (a cleaner appearing cuvette), the first laser (serial number (b)(4)) passed calibration with dcyl 225 and 250, and put out more accurate power (dcyl 710 power output went from 129% to 106% with new cuvette).The same new cuvette was placed into the second laser (serial number (b)(4)), it passed calibration dcyl 225, but still failed calibration dcyl 250.Additional information was received on 10-jan-2016 from a company representative.The following information was obtained.It was confirmed that an on-site investigation of the products took place on 30-nov-2016 to 01-dec-2016.Both products ((b)(4)) failed to calibrate (calibration percentage 61-62 % and 64-65 % with systems (b)(4), respectively).It was confirmed by the reporter that the reported findings by the customer were verified.It was concluded that a contaminated cuvette was found to be the main reason for the calibration issue reported.The devices had functioned correctly and particularly in a safe way preventing the use when the optical losses were too large according to the calibration port measurements (transmission out of the specified range (70-99 %)).By using a new and clean cuvette the calibration was passed with (b)(4) and the dcyl250 fiber indicating that the initial cuvette used in the system was causing excess losses.The cuvette was visually inspected and it was visually verified that the surface of cuvette was not perfectly clean.After a successful calibration with a new cuvette and dcyl250 fiber ((b)(4)) the calibrated power was measured with an external optical power meter (modulight eqid174) and was found to be 2390 mw (i.E.Close to upper limit for the output optical power).It was also observed that the fiber losses are somewhat output power dependent and can contribute to the actual calibrated power when the power setting differs from the specified calibration power (400 mw).The investigations also showed the sensitivity to the external factors due to the specified calibration procedure using different fiber types with the same calibration factors.Due to the close-to-the-specification limit measurement values of the calibrated power, recalibration/fine-tuning of the power calibration factors (sphere and laser module) was done for these the 2 units ((b)(4)).When following the specified calibration procedure, the device needs to handle different fiber types with significant differences in losses and response factors in the calibration port.This means that the window at which the calibration passes becomes in practice more limited than 70-99 % and the device is more sensitive to the external conditions / factors such fiber-to-fiber loss variation, cuvette condition, fiber positioning in the calibration port during calibration etc.The impact of removal of the cuvette during the calibration was investigated at modulight factory using another device ((b)(4)).By default the calibration port response is assumed to be higher without a cuvette and therefore the calibrated power is expected to be lower than when using a cuvette during the calibration.The calibration tests without a cuvette in place were in line with this assumption.Therefore, it was concluded that it is unlikely that the treatment power and dose would have been excessive.The results indicate that it is likely that the dose has been within the correct range.The investigation on the calibration without a cuvette indicate that is not likely that during the treatment the dosing would have been out of the specification and no harm for the patient is expected.In the operator's manual / user manual page 32 (5.7.4 calibration, (b)(4) user manual page 32) the cuvette must be used during the calibration as the device has been calibrated with a cuvette and therefore the removal of the cause unnecessary uncertainty to the treatment dose.The outcome of under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating is recovered.
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Event Description
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A medical science liaison reported on 01-dec-2016 that an elderly male patient of unknown age experienced being under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating after administration of photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) and photofrin 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.The patient's significant past medical history included a bad heart.No other information was provided regarding the patient's medical history, concurrent conditions, or other concomitant medications.On an unknown date, the patient started photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number 684613) and photofrin 630 pdt laser (serial number (b)(4)) both for the esophageal pdt treatment.On (b)(6) 2016, the patient experienced under anesthesia longer than he should have because the fibers were not calibrating.The patient ended up having to go to the intensive care unit on the ventilator after the pdt case on (b)(6) 2016.Both lasers successfully calibrated (with multiple attempts) the dcyl 210, 710, 725, 750, however, both lasers failed calibration (with multiple attempts) for the dcyl 225, 250.Both lasers also put out too much power (see relevant laboratory tests), with laser (serial number (b)(4)) putting out the highest power at a not acceptable level.The reporter stated that some of the fibers failed.The cuvette in the lasers was switched out for a different cuvette (a cleaner appearing cuvette), the first laser (serial number (b)(4)) passed calibration with dcyl 225 and 250, and put out more accurate power (dcyl 710 power output went from 129% to 106% with new cuvette).The same new cuvette was placed into the second laser (serial number (b)(4)), it passed calibration dcyl 225, but still failed calibration dcyl 250.The outcome of under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating is unknown.The reporter did not provide their assessment of the causal relationship of the event to photofrin (porfimer sodium) use.Additional information was received on 10-dec-2016 from a company representative.The following additional information was obtained.The patient was confirmed to have recovered and was released from the icu.Correction report a physician reported to the medical science liaison on 01-dec-2016 that an elderly male patient of unknown age experienced being under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating after administration of photofrin (portimer sodium) for esophageal cancer and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) for the esophageal pdt treatment.This is 1 of 2 reports received from the same reporter [(b)(4) (3010119152-2017-00001)].The patient's significant past medical history included a bad heart.No other information was provided regarding the patient's medical history, concurrent conditions, or other concomitant medications.On an unknown date, the patient started photofrin (portimer sodium) for an unknown indication and co-suspect device's photofrin 630 pdt laser (serial number (b)(4)) for the esophageal pdt treatment.On (b)(6) 2016, the patient experienced under anesthesia longer than he should have because the fibers were not calibrating.The patient ended up having to go to the intensive care unit on the ventilator after the pdt case on (b)(6) 2016.Two lasers ((b)(4)) were successfully calibrated (with multiple attempts) the dcyl 210, 710, 725, 750, however, both lasers failed calibration (with multiple attempts) for the dcyl 225, 250.Both lasers also put out too much power (see relevant laboratory tests), with laser (serial number (b)(4)) putting out the highest power at a not acceptable level.The reporter stated that some of the fibers failed.The cuvette in the lasers was switched out for a different cuvette (a cleaner appearing cuvette), the first laser (serial number (b)(4)) passed calibration with dcyl 225 and 250, and put out more accurate power (dcyl 710 power output went from 129% to 106% with new cuvette).The same new cuvette was placed into the second laser (serial number (b)(4)), it passed calibration dcyl 225, but still failed calibration dcyl 250.Additional information was received on 10-jan-2016 from a company representative.The following information was obtained.It was confirmed that an on-site investigation of the products took place on 30-nov-2016 to 01-dec-2016.Both products ((b)(4)) failed to calibrate (calibration percentage 61-62 % and 64-65 % with systems (b)(4), respectively).It was confirmed by the reporter that the reported findings by the customer were verified.It was concluded that a contaminated cuvette was found to be the main reason for the calibration issue reported.The devices had functioned correctly and particularly in a safe way preventing the use when the optical losses were too large according to the calibration port measurements (transmission out of the specified range (70-99 %)).By using a new and clean cuvette the calibration was passed with (b)(4) and the dcyl250 fiber indicating that the initial cuvette used in the system was causing excess losses.The cuvette was visually inspected and it was visually verified that the surface of cuvette was not perfectly clean.After a successful calibration with a new cuvette and dcyl250 fiber ((b)(4)) the calibrated power was measured with an external optical power meter (modulight eqid174) and was found to be 2390 mw (i.E.Close to upper limit for the output optical power).It was also observed that the fiber losses are somewhat output power dependent and can contribute to the actual calibrated power when the power setting differs from the specified calibration power (400 mw).The investigations also showed the sensitivity to the external factors due to the specified calibration procedure using different fiber types with the same calibration factors.Due to the close-to-the-specification limit measurement values of the calibrated power, recalibration/fine-tuning of the power calibration factors (sphere and laser module) was done for these the 2 units (684613 and 684614).When following the specified calibration procedure, the device needs to handle different fiber types with significant differences in losses and response factors in the calibration port.This means that the window at which the calibration passes becomes in practice more limited than 70-99 % and the device is more sensitive to the external conditions / factors such fiber-to-fiber loss variation, cuvette condition, fiber positioning in the calibration port during calibration etc.The impact of removal of the cuvette during the calibration was investigated at modulight factory using another device (685812).By default the calibration port response is assumed to be higher without a cuvette and therefore the calibrated power is expected to be lower than when using a cuvette during the calibration.The calibration tests without a cuvette in place were in line with this assumption.Therefore, it was concluded that it is unlikely that the treatment power and dose would have been excessive.The results indicate that it is likely that the dose has been within the correct range.The investigation on the calibration without a cuvette indicate that is not likely that during the treatment the dosing would have been out of the specification and no harm for the patient is expected.In the operator's manual / user manual page 32 (5.7.4 calibration, ml7710-630-pin user manual page 32) the cuvette must be used during the calibration as the device has been calibrated with a cuvette and therefore the removal of the cause unnecessary uncertainty to the treatment dose.The outcome of under anesthesia longer than he should have, ended up having to go to the intensive care unit on the ventilator after the pdt and the fibers weren't calibrating is recovered.
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