MAUDE Adverse Event Report: VYAIRE MEDICAL INC. MICROBLENDER; MIXER,BREATHING GASES,ANESTHESIA INHALATION

Model Number	MICBLNDR,.15-1.0/2-16 LPM,DISS,CE,LO
Medical Device Problem Code	Mechanical Problem (1384)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/26/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Vyaire medical file identification: (b)(4).The suspect device was not returned for evaluation.Therefore, root cause cannot be determined.However, the customer was provided with part number for the two flow meters attached to the blender.No further customer activity has occurred.Vyaire medical will submit a supplemental report in accordance with 21 cfr section 803.56 if additional information becomes available.
Event or Problem Description
The customer reported to vyaire medical that the microblender component was needing a tubing that goes from the flow meter to the blender as the flow meter tubing was leaking.The customer confirmed that there was no patient associated with the reported event.

• Brand Name: MICROBLENDER
• Common Device Name: MIXER,BREATHING GASES,ANESTHESIA INHALATION
• Manufacturer (Section D): VYAIRE MEDICAL INC.; 26125 n. riverwoods blvd.; mettawa IL 60045
• Manufacturer (Section G): VYAIRE MEDICAL INC.; 1100 bird center drive; palm springs CA 92262
• Manufacturer Contact: erika bonilla ; 510 technology dr; irvine, IL 92618 ; 7149227837
• MDR Report Key: 14492473
• Report Number: 2021710-2022-16074
• Device Sequence Number: 14954770
• Product Code: BZR
• UDI-Device Identifier: 10190752174726
• UDI-Public: (01)10190752174726(11)20060302
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K883038
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/26/2022

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 Model Number: MICBLNDR,.15-1.0/2-16 LPM,DISS,CE,LO
• Device Catalogue Number: 10042A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/26/2022
• Initial Report FDA Received Date: 05/24/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown