MAUDE Adverse Event Report: COVIDIEN LP - SUPERDIMENSION INC SUPERDIMENSION; INSTRUMENT, BIOPSY

Model Number	SDBF1000
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hemorrhage/Blood Loss/Bleeding (1888)
Date of Event	01/12/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Bleeding is a known short-term complication when a lung biopsy is performed during a transbronchial lung biopsy or ct guided percutaneous biopsy.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, during a procedure, the physician used the tower with a kit, navigated to the target and used radial ebus for confirmation.Then used the following endoscopic tools; brush, forceps, and supertrax needle.The physician was able to complete the enb portion of the case, however, the patient experienced bleeding.Epinephrine, saline and tamponade to resolve the bleeding.The physician was able to tamponade the biopsy site with scope to control and get bleeding to stop.Out of an abundance of caution the patient was left intubated and admitted for overnight observation in the surgical intensive care unit.

• Brand Name: SUPERDIMENSION
• Common Device Name: INSTRUMENT, BIOPSY
• Manufacturer (Section D): COVIDIEN LP - SUPERDIMENSION INC; 161 cheshire lane, suite 100; plymouth MN 55441
• MDR Report Key: 11272490
• Report Number: 3004962788-2021-00010
• Device Sequence Number: 14338342
• Product Code: KNW
• UDI-Device Identifier: 10884521200517
• UDI-Public: 10884521200517
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: K925392
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 02/03/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: SDBF1000
• Device Catalogue Number: SDBF1000
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/12/2021
• Initial Report FDA Received Date: 02/03/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 72 YR