MAUDE Adverse Event Report: BAXTER HEALTHCARE CORPORATION PRISMAFLEX SETS (HF); DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM

Catalog Number 107142

Device Problems Fluid/Blood Leak (1250); Protective Measures Problem (3015); Air/Gas in Device (4062)

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

Event Date 10/09/2023

Event Type  malfunction  

Manufacturer Narrative

E1: initial reporter address: (b)(6) h10: a batch review was conducted and there were no deviations found related to this reported condition during the manufacture of this lot.The device was not received for evaluation; therefore, a device analysis could not be completed.Should additional relevant information become available, a supplemental report will be submitted.

Event Description

It was reported an alarm-treatment-air foam in blood triggered on a prismaflex hf1400 set.During continuous renal replacement therapy, the machine started to alarm for air even though no air was present in the circuit.Therapy was halted and the nurse attempted to return the blood; however, the nurse was unable to return the circuit of blood.The patient was then disconnected, and circuit lines were clamped to remove from the prismaflex machine.The alarm continued during removal of the filter set saying, ¿patient was still connected¿ and saying, ¿lines were not clamped¿, even though patient was not connected to machine and all clamps on filter set were closed.The nurse had to override the machine to remove the filter set.The lines were re-primed, and all connections were triple verified.As soon as therapy was restarted, air was observed being pulled into the machine at the vascath site.Therapy was again discontinued and the patient was disconnected.The alarm again showed ¿patient was still connected¿ and ¿lines were not clamped¿ even though patient was disconnected, and all lines were clamped.The machine was removed from service.The patient lost 4 circuits of blood at approximately 180ml each.There was no report of patient injury or medical intervention associated with this event.No additional information is available.

• Brand Name: PRISMAFLEX SETS (HF)
• Type of Device: DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
• Manufacturer (Section D): BAXTER HEALTHCARE CORPORATION; deerfield IL
• Manufacturer (Section G): BAXTER HEALTHCARE - MEYZIEU; 7, av lionel terray, b.p. 126; meyzieu cedex rhone 69883 ; FR 69883
• Manufacturer Contact: 25212 w. illinois route 120; round lake, IL 60073 ; 2242702068
• MDR Report Key: 18088127
• MDR Text Key: 327628628
• Report Number: 9616026-2023-00089
• Device Sequence Number: 1
• Product Code: KDI
• UDI-Device Identifier: 07332414069315
• UDI-Public: (01)07332414069315
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K042938
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date: 11/07/2023

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 Catalogue Number: 107142
• Device Lot Number: 22J0062
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 10/09/2023
• Initial Date FDA Received: 11/07/2023
• 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
• Treatment: PRISMAFLEX MACHINE