MAUDE Adverse Event Report: ARROW INTERNATIONAL LLC EPIDURAL CATHETERIZATION KIT; Anesthesia conduction kit

Model Number IPN920609

Device Problem Fluid/Blood Leak (1250)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 09/20/2022

Event Type  malfunction  

Manufacturer Narrative

Qn#(b)(4).The device has not been returned for investigation.Teleflex will continue to monitor and trend related events.

Event Description

On (b)(6) 2022 a catheter was observed leaking at the start of the procedure as liquid was not going inside the patient but in the dressing.A second attempt was made with a new catheter and the same problem persisted.The patient had to have two ineffective epidurals in a row.The patient needed a cesarean section which required spinal anesthesia.The customer reported that they were unsure where the leak occurred on the catheter.

Event Description

On 20 september 2022 a catheter was observed leaking at the start of the procedure as liquid was not going inside the patient but in the dressing.A second attempt was made with a new catheter and the same problem persisted.The patient had to have two ineffective epidurals in a row.The patient needed a cesarean section which required spinal anesthesia.The customer reported that they were unsure where the leak occurred on the catheter.

Manufacturer Narrative

(b)(4).The customer reported the catheter was leaking.The customer returned one flat filter, one snaplock assembly, and one epidural catheter.The returned components were received connected.The returned components were visually examined with and without magnification.Visual examination of the returned flat filter and snaplock assembly revealed both components appear typical with no observed defects or anomalies.Visual examination of the returned catheter also revealed that the catheter appears used as biological material can be seen on the inner coils and adhesive can be seen on the outer extrusion.No other defects or anomalies were observed.Functional inspection was performed on the returned sample.A functional leak test was performed using the returned catheter and snaplock assembly with the lab leak tester.The proximal end of the catheter was inserted into the snaplock assembly until it bottomed out and the components were locked.The catheter was confirmed to be secured by tugging gently.The components were then connected to the lab leak tester and the pressure was increased to 10 psi to establish flow.The distal end of the catheter was then capped off and the pressure was increased to 25 psi for 30 seconds.No leak was observed.In summary, the reported complaint of the catheter leaking could not be confirmed based on the sample received.A device history record review was performed on the epidural catheter with no evidence to suggest a manufacturing related issue.The returned catheter passed a leak test.There were no functional issues found with the returned sample.No further action is required at this time.

• Brand Name: EPIDURAL CATHETERIZATION KIT
• Type of Device: Anesthesia conduction kit
• Manufacturer (Section D): ARROW INTERNATIONAL LLC; morrisville NC
• Manufacturer (Section G): ARROW INTERNATIONAL CR, A.S.; jamska 2359/47; zdar nad sazavou 591 0 1; EZ 591 01
• Manufacturer Contact: jasmine brown ; 3015 carrington mill blvd; morrisville, NC 27560 ; 9193614124
• MDR Report Key: 15512406
• MDR Text Key: 300904546
• Report Number: 3006425876-2022-00885
• Device Sequence Number: 1
• Product Code: CAZ
• Combination Product (y/n): N
• Reporter Country Code: FR
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 09/21/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/30/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: IPN920609
• Device Catalogue Number: FR-05501-04
• Device Lot Number: 71F22E1472
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 11/04/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 05/25/2022
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: A
• Patient Sequence Number: 1
• Treatment: N/A.