TERUMO CARDIOVASCULAR SYSTEMS CORP. HX2 TEMPERATURE MANAGEMENT SYSTEM; CONTROLLER, TEMPERATURE, CARDIOPULMONARY BYPASS-HX2 TEMPERATURE MANAGEMENT SYS.
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Model Number 809810 |
Device Problem
Insufficient Information (3190)
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Patient Problem
Abscess (1690)
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Event Date 02/20/2013 |
Event Type
Injury
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Manufacturer Narrative
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(b)(4).This information was received by mail on 05-jan-2016 via a voluntary event report (mw5058676) from the fda.This complaint is related to mdr #1828100-2016-00033, mdr #1828100-2016-00034, and mdr #1828100-2016-00035.Per follow-up with the perfusionist (ccp) on 21-jan-2016: in regards to all of our heater cooler units, we follow the manufacturer¿s recommendations for cleaning.We clean the units weekly with cip-100, our night staff check the chlorine levels daily and add chlorine if necessary to obtain 3-5 parts per million (ppm).All of our preventive maintenance (pms) are handled and scheduled by the manufacturer.No alleged deficiency, s/n unknown.
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Event Description
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It was reported the patient developed empyema and a blood stream infection with mycobacterium abscessus four months after a double lung transplantation requiring use of the device with cardiopulmonary bypass (cpb) procedure.The device was not changed out.The surgical procedure was completed successfully.Per the clinical review on 11-jan-2016: manufacturer clinical services staff spoke with the user facility physicians (mds) of the infectious disease section.Our conversation was in regards to the medwatch reports filed by the hospital in reference to the heater cool unit.This patient was diagnosed with a mycobacterium abscesses infection after a double lung transplant.The transplant occurred on (b)(6) 2012 and the infection was diagnosed on (b)(6) 2013.The patient is alive today.According to both mds, there is no connection or association between the heater cooler unit and the patient infection.The hospital was mandated by (b)(6) to retrospectively look back the previous four years for patients that developed mycobacterium infections post cardiothoracic surgery where cpb was used and a heater cooler unit was used during the procedure.This mandate followed the food and drug administration (fda) and center of disease control (cdc) safety communications (in regards to mycobacterium infections associated with heater-coolers) in (b)(6) 2015.According to the mds, they would not have filed the medwatch report if this mandate was not in place, because there was no medical or laboratory data to associate the use of the heater cooler unit with these infections.This heater cooler unit has been used and continues to be used at the hospital.According to both mds, there is mycobacteria in the (b)(6) and (b)(6) water system and they theorize this was the likely cause of infection in these post-transplant and immunosuppressed patients.There was no delay in the procedure and no blood loss associated with the use of the heater cooler unit.The procedure was completed as scheduled and nothing was changed out during the procedure.
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Manufacturer Narrative
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The reported complaint was not verifiable.No product is being returned for review.The customer stated there was no product deficiency.If additional information becomes available on this complaint that would alter the facts and/or conclusion, a follow-up emdr will be filed accordingly.
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