MAUDE Adverse Event Report: ARROW INTERNATIONAL INC. EPIDURAL CATHETERIZATION KIT; ANESTHESIA CONDUCTION CATHETER

Catalog Number SJ-05501

Device Problem Break (1069)

Patient Problem No Information (3190)

Event Date 01/21/2020

Event Type  malfunction  

Manufacturer Narrative

(b)(4).The device has not been returned for investigation.Teleflex will continue to monitor and trend related events.

Event Description

Medwatch# (b)(4).The patient had a teleflex arrow epidural catheter for pain control r/t a total knee arthroplasty.Upon removal of the catheter, despite no resistance, the catheter was not intact once removed.The plastic sheath on the tip of the catheter was broken off approximately 2cm from the end.The metal wire within the catheter was not frayed or broken.Evidence of epidural fragment retained left lateral and posterior aspects of l3 vertebral body with portion extending through right aspect l2-3 intralumbar space.No contact information listed.

Manufacturer Narrative

Qn# (b)(4).A device history record review was performed on the epidural catheter with no relevant findings.The ifu for this kit, e-17019-109a; rev.07, was reviewed as a part of this complaint investigation.The ifu warns the end user, "never advance catheter more than 5 cm beyond the needle tip.Advancing catheter more than 5 cm increases the likelihood of catheter-related complications." the ifu warns the user, "never tug or quickly pull on catheter during removal from patient to reduce risk of catheter breakage.Do not apply additional tension on the catheter if catheter begins to stretch excessively.Reposition patient to open the vertebral interspaces and re-attempt removal if resistance is encountered or if catheter stretches excessively during removal." a corrective action is not required at this time as a potential root cause could not be determined based upon the information provided and without a sample.Complaint verification testing could not be performed as no sample was returned for analysis.A device history record review was performed on the epidural catheter with no evidence to indicate a manufacturing related issue.Therefore, the potential cause of the catheter tip breaking could not be determined based upon the information provided and without a sample.

Event Description

Medwatch# mw5092444.The patient had a teleflex arrow epidural catheter for pain control r/t a total knee arthroplasty.Upon removal of the catheter, despite no resistance, the catheter was not intact once removed.The plastic sheath on the tip of the catheter was broken off approximately 2cm from the end.The metal wire within the catheter was not frayed or broken.Evidence of epidural fragment retained left lateral and posterior aspects of l3 vertebral body with portion extending through right aspect l2-3 intralumbar space.No contact information listed.

• Brand Name: EPIDURAL CATHETERIZATION KIT
• Type of Device: ANESTHESIA CONDUCTION CATHETER
• Manufacturer (Section D): ARROW INTERNATIONAL INC.; reading PA
• MDR Report Key: 9694266
• MDR Text Key: 179256902
• Report Number: 1036844-2020-00064
• Device Sequence Number: 1
• Product Code: BSO
• Combination Product (y/n): N
• PMA/PMN Number: K140110
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other
• Type of Report: Initial,Followup
• Report Date: 02/06/2020

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: 02/28/2021
• Device Catalogue Number: SJ-05501
• Device Lot Number: 23F19J0362
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 02/06/2020
• Initial Date FDA Received: 02/11/2020
• Supplement Dates Manufacturer Received: 03/25/2020
• Supplement Dates FDA Received: 03/26/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1