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It was reported on 07aug2020, that the arctic sun device, sn (b)(4), was displaying an alert 01 (patient line open) and there was no flow on the device.
Therapy had been ongoing for one hour.
The nurse phoned ms&s for troubleshooting assistance.
Ms&s advised the nurse on draining the gel pads, disconnecting and reconnecting, and verifying a secure connection of the fluid delivery line on the back of the device.
The nurse noted there was dust on the back of the device.
Ms&s advised clearing the dust and ensuring the device was not placed against the wall.
All lines were straight with no bends or kinks and therapy was restarted.
19.
7c; 19.
6c; 18.
3c; 5c; flow rate 2.
9 l/m; inlet pressure -7.
4 psi; circulation pump command 0%; heater command 28%; water rate level 5; system hours 1614.
3; pump hours 1447.
7.
The flow rate leveled out at 2.
6 l/m.
The nurse was advised to call back if any additional issues arose.
The nurse phoned ms&s two hours later and reported the device was not cooling the patient.
The target temperature was 33c.
The patient¿s temperature was 34.
7c via an esophageal probe and 37.
7c via a rectal temperature probe.
Flow rate was at 2.
8l/m, water temperature 34.
7c and the trend indicator was thermoneutral.
Ms&s discussed temperature discrepancies between the two probes and encouraged managing therapy with the esophageal probe.
Ms&s had the nurse place the device in manual mode at 10c.
Over approximately twenty minutes, the device water temperature dropped: was 15c; 15.
1c; 18c; 13c; flow rate 2.
7 l/m; inlet pressure was -7.
0 psi; circulation pump command 71%; mixing pump command was 100%.
Ms&s advised the nurse on how to remove the device from manual mode.
The nurse was advised that if the patient¿s temperature did not increase and the water temperature of the device increased, the device would need to be swapped.
It was also advised that routine maintenance may assist if the device is dirty and potentially blocking airflow to the chiller, prohibiting efficient cooling.
Ms&s placed a follow-up phone call to the nurse an hour later and there was no response.
A voicemail message was left.
During a follow-up phone call on 17aug2020 by an fa specialist, the nurse advised that the device had been swapped out and that there were no further therapy issues.
The nurse reported the patient expired and referred the fa specialist to the charge nurse.
The charge nurse stated therapy had been discontinued at the request of the patient¿s family.
Additional information was received on 18aug2020 during a clinical follow-up phone call with the icu charge nurse.
The patient was a (b)(6) year-old-male who was admitted to the facility status post cardiac arrest.
The patient was found in his yard unresponsive and experienced two ventricular fibrillation cardiac arrests with cardiopulmonary resuscitation.
The patient had a history of hypertension and back pain.
Patient was admitted to the facility on (b)(6) 2020.
All medical care was withdrawn on (b)(6) 2020 and patient was placed on comfort care measures only.
The patient expired on 08aug2020.
The nurse stated the death was due to his condition and not related to the device.
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