MAUDE Adverse Event Report: EDWARDS LIFESCIENCES DR PRESSURE MONITORING KIT

Model Number DPTUNKNOWN

Device Problem Incorrect, Inadequate or Imprecise Result or Readings (1535)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 06/15/2021

Event Type  malfunction  

Manufacturer Narrative

Follow up is on going to clarify whether the device is available for evaluation.An investigation has been initiated to consider any potential factors that may have contributed to this complaint.A supplemental report will be forthcoming with the evaluation results.The exact lot number was unknown, therefore review of the manufacturing records could not be completed.Patient demographics were requested but unable to be obtained.

Event Description

As reported, during use in a cardiac arrest survivor who was unconscious, of this disposable pressure transducer (dpt), the measured blood pressure was higher than the pressure measured by the cardiologist.The cardiologist used philips hemo system with an acist cvi angio touch kit.There was no error message displayed.There was no allegation of patient injury.The product was available for evaluation.

Manufacturer Narrative

It was confirmed that the device was not available for evaluation as it was discarded by the facility.Without return of the unit it is not possible to determine if some damage or defect existed on the unit that could have contributed to the event.It is not known if some procedural factors may have contributed to the event.Per the ifu: poor dynamic response can be caused by air bubbles, clotting, and excessive lengths of tubing, excessively compliant pressure tubing, small bore tubing, loose connections, or leaks.The assembly may be tested for dynamic response by observing the pressure waveform on an oscilloscope or monitor.Bedside determination of the dynamic response of the catheter, monitor, kit and transducer system is done after the system is flushed, attached to the patient, zeroed and calibrated.A square wave test may be performed by pulling the snap tab device and releasing quickly.Pressure readings can change quickly and dramatically because of loss of proper calibration, loose connection, or air in the system.Abnormal pressure readings should correlate with the patients clinical manifestations.Complaint histories for all reported events are reviewed against trending control limits on a monthly basis and any excursions above the control limits are assessed and documented as a part of the monthly review.H3 other text : device discarded by facility.

Manufacturer Narrative

Additional information was received that the patient was not treated based on the erroneous values.The statement included in the initial mdr was referring to the usual protocol for treatment for low blood pressure.Furthermore, it was indicated that the measured invasive blood pressure was systolic blood pressure of 100 mmhg, the cardiologist a systolic blood pressure of 50 mmhg with the acist device.

• Brand Name: PRESSURE MONITORING KIT
• Type of Device: PRESSURE MONITORING KIT
• Manufacturer (Section D): EDWARDS LIFESCIENCES DR; parque industrial de itabo; carr. sanchez km 18.5; haina, san cristobal
• MDR Report Key: 12141351
• MDR Text Key: 260699059
• Report Number: 2015691-2021-03968
• Device Sequence Number: 1
• Product Code: DXO
• Combination Product (y/n): N
• PMA/PMN Number: K183413
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,health professional,o
• Type of Report: Initial,Followup,Followup
• Report Date: 08/20/2021

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: No Information
• Device Model Number: DPTUNKNOWN
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 06/15/2021
• Initial Date FDA Received: 07/09/2021
• Supplement Dates Manufacturer Received: 07/17/2021; 08/17/2021
• Supplement Dates FDA Received: 08/10/2021; 08/20/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: PHILIPS HEMO SYSTEM, ACIST CVI ANGIO TOUCH KIT; PHILIPS HEMO SYSTEM, ACIST CVI ANGIO TOUCH KIT