MAUDE Adverse Event Report: MALLINCKRODT PHARMACEUTICALS IRELAND LIMITED CELLEX PHOTOPHERESIS SYSTEM

Catalog Number CLXECP

Device Problem Display or Visual Feedback Problem (1184)

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

Event Date 07/29/2021

Event Type  malfunction  

Manufacturer Narrative

The system was used for treatment.The case is reportable as a mdr due to the reportable malfucntion clot oberved in the return line.Since this reportable malfunction is only associated with kit, this mdr will only be against the kit.A batch record review for kit lot j153 was conducted.There were no non-conformances associated with this lot.This lot met all release requirements.A review of kit lot j153 shows no trends.Trends were reviewed for complaint categories, alarm #17: return pressure, clot observed, alarm #45: red blood cell pump alarm, and alarm #18: system pressure.No trends were detected for these complaint categories.The assessment is based on the information available at the time of investigation.No product was returned for investigation; therefore, it could not be determined if the product met specification based solely on the information provided by the customer.Section 2-10 of the cellex operators manual (1460451 rev.4) on anticoagulant states "caution: individual patients may require a heparin dosage that varies from the recommended dose to prevent post-treatment bleeding or clotting during a treatment.The physician should review the patient's medical condition, medications and platelet count at the time of treatment and use clinical judgement to establish the optimal heparin dosage for each patient." the root cause for the clotting observed could not be determined based on the available information.No further action is required at this time.This investigation is now complete.(b)(4).

Event Description

The customer contacted mallinckrodt to report they observed clots in the return line of their cellex photopheresis kit ("kit") during and extracorporeal photopheresis (ecp) treatment.The customer reported they received an alarm #17: return pressure and alarm #45: red blood cell pump alarm during the treatment.The customer disconnected the return line from the patient and ran a saline bolus.A blood clot was observed to be passing through the return line.The treatment continued and then the instrument prompted an alarm# 18: system pressure.The alarm #18 was resolved and the treatment progressed until an alarm #45 and alarm #17 occurred.The treatment was paused to inspect the kit and clotting was observed in the centrifuge bowl.The ecp treatment was aborted and no residual blood within the kit was returned to the patient.The patient was reported to be in stable condition.The customer did not return product for investigation.

• Brand Name: CELLEX PHOTOPHERESIS SYSTEM
• Type of Device: CELLEX PHOTOPHERESIS SYSTEM
• Manufacturer (Section D): MALLINCKRODT PHARMACEUTICALS IRELAND LIMITED; blanchardstown, dublin, D15 T X2V; EI D15 TX2V
• Manufacturer (Section G): MALLINCKRODT PHARMACEUTICALS IRELAND LIMITED; college business & tech park; cruiserath road; blanchardstown, dublin, D15 T X2V; EI D15 TX2V
• Manufacturer Contact: megan vernak ; shelbourne building; 53 frontage rd suite 300; hampton, NJ 08827 ; 9082351030
• MDR Report Key: 12342623
• MDR Text Key: 268698600
• Report Number: 2523595-2021-00072
• Device Sequence Number: 1
• Product Code: LNR
• Combination Product (y/n): Y
• Reporter Country Code: CA
• PMA/PMN Number: P860003
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,health professional
• Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date: 08/19/2021

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: Health Professional
• Device Expiration Date: 12/01/2022
• Device Catalogue Number: CLXECP
• Device Lot Number: J153
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 07/29/2021
• Initial Date FDA Received: 08/19/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 12/11/2020
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Age: 55 YR