It was reported that during use, this disposable pressure transducer (dpt) showed central venous pressure (cvp) value that was doubled.The value provided was 25, however the doctor expected 12.The dpt kit was exchanged to a new one and the value was then correct.The patient was not treated according to wrong values.It was unknown if any error messages were displayed.There was no allegation of patient injury.The device was available for evaluation.Patient demographic information is unavailable.
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One single dpt kit was received for evaluation.The reported event of pressure measurement issue was not confirmed.The dpt zeroed and sensed pressure accurately on the pressure monitor.Pressure did not show any drift during output drift testing and met specifications.Electrical testing showed that both input impedance and output impedance were within specifications.No leakage or occlusion was detected from the kit during pressure test.No visible damage was observed from the kit.A device history record review was completed and documented that device met all specifications upon distribution.A supplement report will be sent if any non conformances are found related to the manufacturing processes.Poor dynamic response can be caused by air bubbles, clotting, and excessive lengths of tubing, excessively compliant pressure tubing, small bore tubing, loose connections, or leaks.The assembly may be tested for dynamic response by observing the pressure waveform on an oscilloscope or monitor.Bedside determination of the dynamic response of the catheter, monitor, kit and transducer system is done after the system is flushed, attached to the patient, zeroed and calibrated.A square-wave test may be performed by pulling the snap tab device and releasing quickly.Pressure readings can change quickly and dramatically because of loss of proper calibration, loose connection, or air in the system.Pressure readings should correlate with the patient¿s clinical manifestations.It is not known if user or procedural factors may have contributed to the stated event.In this event, there was no patient compromise noted.Complaint histories for all reported events are reviewed against trending control limits on a monthly basis and any excursions above the control limits are assessed and documented as a part of the monthly review.
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