MAUDE Adverse Event Report: TELEFLEX MEDICAL LMA SUPREME SIZE 5

Model Number	IPN902076
Medical Device Problem Code	Deformation Due to Compressive Stress (2889)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/27/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Qn# (b)(4).
Event or Problem Description
It was reported that "when the doctor used it he found the inflation line was kinked and therefore the valve wouldn't inflate.He removed the mask and changed to an igel".No patient injury or consequence reported.Patient condition reported as "fine".
Event or Problem Description
It was reported that "when the doctor used it he found the inflation line was kinked and therefore the valve wouldn't inflate.He removed the mask and changed to an igel".No patient injury or consequence reported.Patient condition reported as "fine".
Additional Manufacturer Narrative
(b)(4).Complaint verification testing could not be performed as no sample was returned for analysis.A device history record review was performed and no relevant findings were identified.Without the device to evaluate the complaint could not be confirmed and the probable cause could not be determined from the available information.Teleflex will continue to monitor and trend for reports of this nature.If the sample becomes available at a later date a follow up report will be submitted with investigation results.

• Brand Name: LMA SUPREME SIZE 5
• Common Device Name: LMA SUPREME
• Manufacturer (Section D): TELEFLEX MEDICAL; athlone
• MDR Report Key: 12086484
• Report Number: 9681900-2021-00020
• Device Sequence Number: 19670137
• Product Code: CAE
• UDI-Device Identifier: 05060112310836
• UDI-Public: 05060112310836
• Combination Product (Y/N): N
• Initial Reporter Country: SF
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/07/2021

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
• Operator of Device: Health Professional
• Device Expiration Date: 02/28/2023
• Device Model Number: IPN902076
• Device Catalogue Number: 175050
• Device Lot Number: QMAM43
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 06/07/2021
• Supplement Date Received by Manufacturer: 07/21/2021
• Initial Report FDA Received Date: 06/29/2021
• Supplement Report FDA Received Date: 07/22/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: IGEL LMA; IGEL LMA; IGEL LMA