MAUDE Adverse Event Report: VYAIRE MEDICAL ENFLOW; ENFLOW DISPOSABLE IV FLUID/BLOOD WARMER CARTRIDGE MODEL 200

Model Number 980200EU

Device Problem Particulates (1451)

Patient Problem No Patient Involvement (2645)

Event Date 03/11/2019

Event Type  malfunction  

Manufacturer Narrative

Vyaire file identification: (b)(4).A recently conducted internal testing with the results received by vyaire medical on 11 march 2019 indicates that there is the potential to elude aluminum from the enflow disposable cartridge during intravenous warming therapy with fluid and blood solutions.As a result, vyaire is initiating an immediate global recall of the enflow disposable cartridges part number 980200eu & 980202eu.Any additional information received from the customer or through vyaire's internal investigation will be included in a follow-up report.

Event Description

A news article by the bmj titled "enflow fluid warming device: warning over risk of aluminium toxicity" was published on march 11, 2019.The article mentions a recent paper in anaesthesia that uncoated aluminium plates in fluid warming systems, such as those used in the enflow system, yielded potentially harmful concentrations of aluminium when using balanced electrolyte solutions.Lead researcher thorsten perl, senior consultant at the university medical centre (b)(6), told the bmj that patients with impaired aluminium elimination from renal insufficiency were at risk of adverse events."an effective coating for aluminium containing medical devices in direct contact with fluids should be recommended," he said.

• Brand Name: ENFLOW
• Type of Device: ENFLOW DISPOSABLE IV FLUID/BLOOD WARMER CARTRIDGE MODEL 200
• Manufacturer (Section D): VYAIRE MEDICAL; 22745 savi ranch pkwy; yorba linda CA 92887
• Manufacturer (Section G): HEALTHCARE TECHNOLOGY INTERNATIONAL LTD.; 15/f block b veristrong; industry 36 au pui wan st; fotan, ; HK
• Manufacturer Contact: stanley tan ; 22745 savi ranch pkwy; yorba linda, CA 92887 ; 7149193324
• MDR Report Key: 8423033
• MDR Text Key: 139111904
• Report Number: 2050001-2019-00022
• Device Sequence Number: 1
• Product Code: LGZ
• UDI-Device Identifier: 10885403286155
• UDI-Public: (01)10885403286155
• Combination Product (y/n): N
• Reporter Country Code: UK
• PMA/PMN Number: K130867
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,literature
• Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Recall
• Type of Report: Initial
• Report Date: 03/12/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/14/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 980200EU
• Device Catalogue Number: 980200EU
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 03/12/2019
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: Yes
• Type of Device Usage: Unknown
• Removal/Correction Number: 3008959444-3/13/19-001-R
• Patient Sequence Number: 1