BAXTER HEALTHCARE CORPORATION PRISMAX SYSTEM; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
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Model Number 955626 |
Device Problems
Backflow (1064); Protective Measures Problem (3015); Air/Gas in Device (4062)
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Patient Problem
Low Blood Pressure/ Hypotension (1914)
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Event Date 04/12/2023 |
Event Type
malfunction
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Event Description
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Baxter prismax continuous rental replacement therapy (crrt) system running without any issues when suddenly negative access pressure alarm was noticed.This registered nurse (rn) inspected patient's hd line and noticed lots of air present in the red access line.Patient was sedated and not moving.Patient's blood pressure suddenly dropped to 70 systolic with mean arterial pressures in the 40s, pressor requirement increased at that time.Access to patient automatically clamped.Rn was unable to return blood to patient due to air/clotting present.Blood also noticed to be backflowing into the dialysate bags.Team lead notified, and machine taken by for further inspection.Patient did end up loosing that filter of blood and needed a unit of packed red blood cells.Patient also returned to normal hemodynamics within 10 minutes.Manufacturer response for baxter prismax crrt machine, prismax (per site reporter) mayo clinic in arizona has been working closely with baxter including multiple site visits for over two and a half years in an attempt to identify the problems and fix the problems.
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Event Description
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Baxter prismax continuous rental replacement therapy (crrt) system running without any issues when suddenly negative access pressure alarm was noticed.This registered nurse (rn) inspected patient's hd line and noticed lots of air present in the red access line.Patient was sedated and not moving.Patient's blood pressure suddenly dropped to 70 systolic with mean arterial pressures in the 40s, pressor requirement increased at that time.Access to patient automatically clamped.Rn was unable to return blood to patient due to air/clotting present.Blood also noticed to be backflowing into the dialysate bags.Team lead notified, and machine taken by for further inspection.Patient did end up loosing that filter of blood and needed a unit of packed red blood cells.Patient also returned to normal hemodynamics within 10 minutes.Manufacturer response for baxter prismax crrt machine, prismax (per site reporter) user facility has been working closely with baxter including multiple site visits for over two and a half years in an attempt to identify the problems and fix the problems.
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Event Description
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Baxter prismax continuous rental replacement therapy (crrt) system running without any issues when suddenly negative access pressure alarm was noticed.This registered nurse (rn) inspected patient's hd line and noticed lots of air present in the red access line.Patient was sedated and not moving.Patient's blood pressure suddenly dropped to 70 systolic with mean arterial pressures in the 40s, pressor requirement increased at that time.Access to patient automatically clamped.Rn was unable to return blood to patient due to air/clotting present.Blood also noticed to be backflowing into the dialysate bags.Team lead notified, and machine taken by for further inspection.Patient did end up loosing that filter of blood and needed a unit of packed red blood cells.Patient also returned to normal hemodynamics within 10 minutes.Manufacturer response for baxter prismax crrt machine, prismax (per site reporter) user facility has been working closely with baxter including multiple site visits for over two and a half years in an attempt to identify the problems and fix the problems.
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Search Alerts/Recalls
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