MAUDE Adverse Event Report: AVANOS MEDICAL INC. CORTRAK 2 ENTERAL ACCESS SYSTEM; DH CORTRAK (EAS)

Model Number	20-0950
Medical Device Problem Codes	Malposition of Device (2616); Physical Resistance/Sticking (4012)
Health Effect - Clinical Codes	Chest Pain (1776); Pneumothorax (2012); Low Oxygen Saturation (2477); Cough (4457)
Date of Event	11/06/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported the patient was admitted to the hospital (b)(6) 2024.Initially intubated (b)(6) 2024 with ogt (oral gastric tube) in place, extubated.On "(b)(6) 2024 and ogt was pulled upon extubation (b)(6) 2024 attempted cortrak placement.At time of placement patient (pt) was on 50l heated high flow o2 (oxygen) plus 15l o2 via mask.Per clinician placing tube, [patient] was coughing/moving during placement.On last placement attempt, [patient] [complained of] pain on [right] side, clinician states they felt resistance, final tracing appears to show feeding tube tip enter the [right] lung then entire feeding tube was immediately removed, [patient's] o2 stats dropped to high 70s - low 80s, tachypneic (30-40 bpm [beats per minute]), [patient] was intubated at 1407 on (b)(6) 2024, chest [x-ray] obtained, radiologist interpretation: interval development of a small the moderate right-sided pneumothorax with the pleural surface approximately 3 cm from the apex.Chest tube placed (b)(6) 2024, then replaced [due to] malposition and replaced a second time on (b)(6) 2024 (three chest tubes total).As of (b)(6) 2024 [patient] remains intubated with ogt and chest tube in place.Hospital policy for initial feeding tube confirmation, chest x-ray.".
Additional Manufacturer Narrative
Monitor, software 2.5.4.Receiver, model version 1.1.0.The actual complaint product was not returned for evaluation.A review of the device history record and udi number are in-progress.All information reasonably known as of 12-dec-2024 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical, inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical, inc.Avanos medical, inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical, inc.Complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an avanos medical, inc.Product is defective or caused serious injury.
Additional Manufacturer Narrative
The device history record for the reported lot number, 22122031, in this complaint was reviewed and the material was produced according to the manufacturing procedures and met the quality requirements.All information reasonably known as of 15-oct-2025 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical, inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical, inc.Avanos medical, inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical, inc.Complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an avanos medical, inc.Product is defective or caused serious injury.

• Brand Name: CORTRAK 2 ENTERAL ACCESS SYSTEM
• Common Device Name: DH CORTRAK (EAS)
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• Manufacturer (Section G): MINNETRONIX, INC.; 1635 energy park dr.; saint paul MN 55108
• Manufacturer Contact: tamara cardona ; 5405 windward parkway; alpharetta, GA 30004 ; 4704485487
• MDR Report Key: 20915475
• Report Number: 3011270181-2024-00131
• Device Sequence Number: 12878319
• Product Code: KNT
• UDI-Device Identifier: 00350770005843
• UDI-Public: (01)00350770005843(240)104720102
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: K240965
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Remedial Action: Notification,Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/15/2025

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: 20-0950
• Device Catalogue Number: 20-0950
• Device Lot Number: N/A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/13/2024
• Supplement Date Received by Manufacturer: 09/15/2025
• Initial Report FDA Received Date: 12/12/2024
• Supplement Report FDA Received Date: 10/15/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/05/2023
• 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: Reuse
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: RU SN (B)(6).
• Outcome Attributed to Adverse Event: Other
• Patient Age: 64 YR
• Patient Sex: Female
• Patient Weight: 94 KG