MAUDE Adverse Event Report: TERUMO BCT TRIMA ACCEL; TRIMA PLATELET SAMPLER, PLASMA, RBC SET

Model Number 82440

Device Problems Device Ingredient or Reagent Problem (2910); Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems No Patient Involvement (2645); No Clinical Signs, Symptoms or Conditions (4582)

Event Date 08/17/2020

Event Type  malfunction  

Manufacturer Narrative

Investigation is in process.A follow-up report will be provided.

Event Description

The customer would like the run data file investigated to determine a possible cause for the elevated white blood cell (wbc) content in the platelet product.There was not a transfusion recipient or patient involved at the time of the residual white blood cell (rwbc) testing, therefore no patient information is reasonably known at the time of the event.Donor unit #: (b)(6).The platelet collection set is not available for return because it was discarded by the customer.

Manufacturer Narrative

This report is being filed to provide additional information in h.6 and h.10 investigation : a review of the device history record (dhr) for this unit showed no irregularities during manufacturing that were relevant to this issue.The donor pre procedure cbc results and trima procedure record were provided to aid in the investigation.Evaluation of the procedure record and the corresponding taps report indicated trima 1t07663 was loaded with an 82440 tubing set and passed the tubing set test.There were no alerts generated.The operator made 15 draw flow adjustments and 6 return flow adjustments throughout the procedure.The procedure completed with rinseback at 63 minutes.The platelets could be labeled as leukoreduced with no product verification messages shown.The donor cbc confirmed the following: - the donor's wbc is elevated but it is still within the normal range of 10e3/ul.5-part differential confirmed that the monocyte count is outside the normal range.The donor's platelet count is also elevated and over the normal range.Root cause : although the system has several methods for detection of wbc contaminations, some events may elude the detection capability of the trima accel system.The following events can occur during the procedure and may contribute to elevated wbc content in the platelet product that the system cannot always detect.A majority of the time, these events will not contribute to elevated wbc content: multiple alerts or flow adjustments that stop/slow the pumps, disrupting the steady-state collection process.Large discrepancy in entered versus actual donor information.Plasma line occlusion or air block that was not large enough to be detected by the system.If the configured platelet concentration during collection is above approximately 3500e3/ul, it is possible that an inaccurate platelet yield scaling factor (ysf) configuration can cause the platelet concentration to exceed the lrs chamber holding capacity due to collecting a higher than expected platelet yield additionally, it is possible that the cause is related to donor specific blood characteristics that may challenge the trima leukoreduction system, including, but not limited to: a higher donor bmi, a donor pre-wbc count that is above the trima accel system expectation, elevated monocyte count, larger than average donor platelet size, and/or smaller than average donor wbc or rbc size.

• Brand Name: TRIMA ACCEL
• Type of Device: TRIMA PLATELET SAMPLER, PLASMA, RBC SET
• Manufacturer (Section D): TERUMO BCT; lakewood CO 80215
• MDR Report Key: 10522519
• MDR Text Key: 211032565
• Report Number: 1722028-2020-00442
• Device Sequence Number: 1
• Product Code: GKT
• UDI-Device Identifier: 05020583824409
• UDI-Public: 05020583824409
• Combination Product (y/n): N
• PMA/PMN Number: BK190332
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional
• Type of Report: Initial,Followup
• Report Date: 09/11/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 04/01/2022
• Device Model Number: 82440
• Device Catalogue Number: 82440
• Device Lot Number: 2004285151
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Initial Date Manufacturer Received: 08/20/2020
• Initial Date FDA Received: 09/11/2020
• Supplement Dates Manufacturer Received: 02/09/2021
• Supplement Dates FDA Received: 02/17/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Other