BAXTER HEALTHCARE PRISMAFLEX HF20; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
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Model Number PRISMAFLEX HF20 |
Device Problem
Output Problem (3005)
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Patient Problem
Appropriate Clinical Signs, Symptoms, Conditions Term / Code Not Available (4581)
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Event Date 09/19/2021 |
Event Type
malfunction
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Event Description
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Prismaflex hf-20 filter blood primed for crrt.Approximately 30 minutes following initiation, effluent in bag was blood tinged.Nephrology & picu team paged, all to bedside to monitor.Patient cell count sent to lab stat: resulted in rbc <2000.Circuit taken down.The patient was put onto a new crrt circuit at 1056, and brand-new filter used.Team noticed pink tinged effluent in bag and pod around 1115, for a second time.Crrt dialysis drew a cell count and sent it to lab stat.No blood leak alarm on crrt pump.Lab resulted rbc <2000.Crrt stopped, and nephrology & picu team paged back to bedside.Patient taken off crrt at 1226.The filters with this lot number have been pulled from service, and the prismaflex machine placed out of service.The concern with blood in the effluent line means there is a break in the filter, and the filter is compromised, allowing dialysate to get to the patient's blood freely.The patient's electrolytes and blood cultures were sent, and patient was on prophylactic antibiotics.The patient¿s labs were within this specific patient¿s norm, and the patient is currently not showing any signs of an infection.
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Event Description
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Prismaflex hf-20 filter blood primed for crrt.Approximately 30 minutes following initiation, effluent in bag was blood tinged.Nephrology & picu team paged, all to bedside to monitor.Patient cell count sent to lab stat: resulted in rbc <2000.Circuit taken down.The patient was put onto a new crrt circuit at 1056, and brand-new filter used.Team noticed pink tinged effluent in bag and pod around 1115, for a second time.Crrt dialysis drew a cell count and sent it to lab stat.No blood leak alarm on crrt pump.Lab resulted rbc <2000.Crrt stopped, and nephrology & picu team paged back to bedside.Patient taken off crrt at 1226.The filters with this lot number have been pulled from service, and the prismaflex machine placed out of service.The concern with blood in the effluent line means there is a break in the filter, and the filter is compromised, allowing dialysate to get to the patient's blood freely.The patient's electrolytes and blood cultures were sent, and patient was on prophylactic antibiotics.The patient¿s labs were within this specific patient¿s norm, and the patient is currently not showing any signs of an infection.
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