The following were reviewed as part of this investigation: patient severity, applicable previous investigation(s), sample analysis, applicable fmea documents, applicable manufacturing records, and labeling.Based on a review of this information, the following was concluded: the complaint of a damaged introducer was confirmed, but the exact cause could not be discerned from the two photographs that were provided for investigation.Both photos showed what appeared to be a microintroducer.The edge at the distal end of the sheath exhibits deformation and the distal end of the sheath tubing was buckled in multiple locations.What appeared to be blood residue was observed throughout the sample.The dilator remained attached to the sheath.A bend was observed in the dilator and overlying sheath.One photo showed the label with part number ck000917 and lot #redx5156.The introducer in the photo matched the characteristics of the 3.5fr x 7cm microintroducer that is contained in the implicated kit.This type of damage can occur during use when the sheath comes in contact with the surrounding tissue of the insertion site.The sheath and dilator should be advanced together as a unit over the guidewire, using a slight rotational motion.Since the damage was observed on the sheath, the complaint was confirmed.A lot history review (lhr) of redx5156 showed no other similar product complaint(s) from this lot number.
|
It was reported "dilator peel apart sheath, issues continue, i was able to salvage this 3 fr.Midline iv dilatator, unable to use this dilator despite skin nick.I avoid skin nicking." additional information received: 03/04/2020 - attempting to advance dilator and sheath over wire, device would not penetrate skin, buckled after making skin nick continued difficulty advancing after 3rd attempt to advance sheath became accordion like.
|