Model Number 10310 |
Device Problems
Microbial Contamination of Device (2303); Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problems
Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 01/01/2020 |
Event Type
malfunction
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Manufacturer Narrative
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Lot number and expiry information are not available at this time.Article citation: coronel, m.L.P., velao, s.R., cedena, m.T., aldea, a.L., valeri, a., garcía, a., velazquez, b.A., lozano, d.S., arce, e.G., lópez, j.M.Autologous lymphapheresis for the production of car-t cells.Bone marrow transplantation.2020.55:698 investigation is in process.A follow-up report will be provided.
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Event Description
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The abstract, "autologous lymphapheresis for the production of car-t cells.Bone marrow transplantation" describes a study that aims to present the authors' experience in the collection of autologous t lymphocytes for the manufacture of car-tcd19 cells in adult patients with refractory or recurrent diffuse large cell lymphoma and follicular lymphoma refractory or in relapse after one line treatment, whose indication was approved by the transplant committee and advanced therapies.There were 18 procedures with a mean age of 48 years.Patients underwent apheresis with variable counts of absolute lymphocytes, with an average of 5044 cells/ml.There were 2 patients where there was microbial contamination that forced the apheresis product to be disposed of.This report is being filed for the two microbial contamination events.Patient information and outcome were not provided in the abstract.The disposable set is not available for return because it was discarded by the customer.
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Manufacturer Narrative
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Investigation: per internal sterility lab documentation, the devices terumo bct manufactures to collect, separate, and store blood products are terminally sterilized to a sterility assurance level (sal) of =10-6.Additionally, a sterility assurance system has been designed and employed to ensure this sal will be achieved for every lot of product manufactured.The sterility assurance system employed at terumo bct ensures the disposable device is not the source of contamination.Since this study involved autologous lymphapheresis for the production of car-t cells over a period of some time, the lot numbers were not provided; therefore, a dhr search could not be conducted for this specific incident.All lots must meet acceptance criteria for release.According to therapeutic apheresis: a physician's handbook, adverse events occur during therapeutic procedures with a frequency of 4.8%.Some of the most common reactions include fever, urticaria, hypocalcemic symptoms, pruritus, dyspnea, tachycardia, and mild hypotension.Transient hypocalcemia associated with apheresis is usually well tolerated.Symptoms often show as paresthesia (tingling) but patients may also experience unusual taste, nausea, lightheadedness, shivering, and tremors.Severe hypocalcemia may also cause muscle contractions and can progress to tetany and seizures if hypocalcemia escalates and is not corrected.Vasovagal incidents occur around (b)(4)% of procedures.The reactions generally manifest as pallor and diaphoresis.In a full blown attack, the reaction progresses from pallor and sweating to pulse slowing and blood pressure decreasing.More severe vasovagal reactions may include nausea, vomiting, and/or convulsions.Root cause: a specific root cause for the reported adverse reactions could not be determined.Adverse events are common side effects of therapeutic apheresis procedures.They are typically caused by the patient's disease state, the rate of ac infusion, the length of the procedure, the patient's sensitivity to the procedure and/or the hemodynamic stress of the procedure.A specific root cause for the bacterial contamination could not be determined.Possible root causes include but are not limited to: - bacteria being introduced at the access site via the patient's catheter.- poor venipuncture technique leads to bacteria introduced at access site resulting in product contamination.- bacteria in source blood resulting in set contamination.
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Event Description
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This study involved autologous lymphapheresis for the production of car-t cells over a period of some time.A request for specific patient information is not feasible.
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Search Alerts/Recalls
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