DATASCOPE CORP. - FAIRFIELD SENSATION PLUS 7.5FR. 40CC; SYSTEM, BALLOON, INTRA-AORTIC AND CONTROL
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Model Number 0684-00-0568-01 |
Device Problems
Inappropriate Waveform (2536); Pressure Problem (3012)
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Patient Problems
Cardiac Arrest (1762); Low Blood Pressure/ Hypotension (1914)
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Event Date 03/02/2021 |
Event Type
Injury
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Manufacturer Narrative
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(b)(6).The device has been returned to the factory and is being evaluated.A supplemental report will be submitted when the evaluation is completed.Complaint record id # (b)(4).
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Event Description
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Medwatch received on 16-march-2021.The patient was about to have emergent coronary angiography, became hypotensive, developed vf and received multiple rounds of defibrillation, cardiopulmonary resuscitation (cpr) and inotropes.The team then placed an iabp.The patient arrested again and received @6 minutes cardiopulmonary resuscitation (cpr) with aggressive resuscitation efforts.A 40cm iabp was placed in excellent position and set at 1:1.There was initially excellent augmentation however, over several minutes time the map persistently dropped requiring confirmation of central pressures with the use of an omniflush catheter placed in the proximal aorta.Again, the patient became hypotensive to the 40s systolic despite aggressive inotropes.The balloon pump waveform had an odd appearance that suggested the patient had no underlying native pressure.This was confirmed by putting the balloon pump on hold which demonstrated no native pressure.Aggressive cardiopulmonary resuscitation (cpr) and resuscitative efforts were reinstituted for an additional 5 minutes which did not result in restoration of a perfusing pressure or rhythm.Therefore all further efforts at resuscitation.
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Event Description
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Medwatch received on 16-march-2021.The patient was about to have emergent coronary angiography, became hypotensive, developed vf and received multiple rounds of defibrillation, cardiopulmonary resuscitation (cpr) and inotropes.The team then placed an iabp.The patient arrested again and received @6 minutes cardiopulmonary resuscitation (cpr) with aggressive resuscitation efforts.A 40cm iabp was placed in excellent position and set at 1:1.There was initially excellent augmentation however, over several minutes time the map persistently dropped requiring confirmation of central pressures with the use of an omniflush catheter placed in the proximal aorta.Again, the patient became hypotensive to the 40s systolic despite aggressive inotropes.The balloon pump waveform had an odd appearance that suggested the patient had no underlying native pressure.This was confirmed by putting the balloon pump on hold which demonstrated no native pressure.Aggressive cardiopulmonary resuscitation (cpr) and resuscitative efforts were reinstituted for an additional 5 minutes which did not result in restoration of a perfusing pressure or rhythm.Therefore all further efforts at resuscitation.
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Manufacturer Narrative
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Additional information: added serial #.Device evaluation: the product was returned with the membrane completely unfolded and blood on the exterior of the catheter.A kink was found on the inner lumen and catheter tubing approximately 68.3cm from the iab tip.The optical fiber was found to be broken at the kinked location.The inner lumen was found occluded with dried blood.The occlusion was unable to be cleared.The optical fiber was found to be broken, confirming the reported problem.We are unable to determine when this may have occurred.A non-conforming material report review was completed for the reported product.No nonconformances were found that are considered to be related to the event.The device history records review concluded that there were no ncmrs, rework, or deviations documented for the reported lot/serial number.Based on the dhr/lhr review results, it was determined that there is no relation between the manufacturing process and the reported failure.The review of the historical data indicates that no other similar complaint was reported for the same lot/serial number and reported failure mode.The overall 24 month product complaint trend data for the period april2019 - march 2021 was reviewed.There were no triggers identified for the review period.Communication/interviews were performed to obtain all possible information.Reference complaint # (b)(4).
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