The customer reported that a pediatric patient with anti¿glomerular basement membrane(anti-gbm) antibody disease was undergoing a therapeutic plasma exchange (tpe) procedure on spectra optia.During rinse back, the operator observed air in the blood warmer tubing.It was reported by the customer that the patient did not receive any air and the procedure was terminated when the air was noticed.Per the customer, no return air line detector (rlad) alarms occurred during the procedure.The patient did not require medical intervention and is reported as stable.The customer declined to provide patient identifier (id).The spectra optia exchange set is not available for return because it was discarded by the customer.
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This report is being filed to provide additional information in initial reporter occupation, device manufacture date, and evaluation codes.Corrected information is provided in model #, serial #, expiration date, catalog #, lot #, other #, udi # and pma/510k.Investigation: a review of the device history record (dhr) for this unit showed no irregularities during manufacturing that were relevant to this issue.Root cause: based on the clinical findings and run data analysis, which confirmed there were norlad alarms indicating air was distal to the rlad, the air in the blood warmer tubing was due to outgassing of the cold saline used for rinseback as it passed through the warmer in the returnline.
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