MAUDE Adverse Event Report: COVIDIEN KANGAROO NASOGASTRIC FEEDING TUBE; TUBES, GASTROINTESTINAL (AND ACCESSORIES)

Catalog Number 888410842

Device Problem Deformation Due to Compressive Stress (2889)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 03/12/2019

Event Type  Injury  

Event Description

This feeding tube kangaroo (covidien brand) 7g weighted dobbhoff tip, rigid port, no stylet was introduced normally by nasal insertion in the pt who was endotracheally intubated on mechanical ventilation at that time.The tube coiled and formed a knot in itself inside the pt during the insertion process without the nurse inserting becoming aware.A kub film was shot to look for placement, and the tube was not seen.A cxr did not reveal the tube either, so it was assumed it had coiled in the pharynx or mouth.The pt's oral cavity was examined, and the tube was not seen in the mouth.We proceeded to pull out the tube, but it was trapped and stuck somewhere, and enough pull force was applied which warranted stopping the attempt.A bronchoscopy was performed inserting the bronchoscope via the opposite nostril which did not find the tube until it was advanced.It had been anchored at the choana because the knot was larger than the size of the choana.The tube was then advanced into the hypopharynx and then fished out the mouth.The knot was untied and the tube was then successfully pulled from the nose.

• Brand Name: KANGAROO NASOGASTRIC FEEDING TUBE
• Type of Device: TUBES, GASTROINTESTINAL (AND ACCESSORIES)
• Manufacturer (Section D): COVIDIEN
• MDR Report Key: 8448232
• MDR Text Key: 139811871
• Report Number: MW5085113
• Device Sequence Number: 0
• Product Code: KNT
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Voluntary
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 03/20/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/22/2019
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 888410842
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Was Device Evaluated by Manufacturer?: No Information
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: N
• Patient Sequence Number: 1
• Patient Outcome(s): Other; Required Intervention
• Patient Age: 57 YR
• Patient Weight: 61