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It was reported that once the extracorporeal membrane oxygenation (ecmo) circuit was primed, a high-pitched whistle sound came from the oxygenator when flows were above 2.0 l/min.The customer made sure the circuit and oxygenator were fully de-aired and tried to run the pump again but had the same whistle sound.At the time of the issue, the gas line was not connected, and pressures were not measured.Pump flow when the whistling occurred was constant between 2.0-5.0 liters.The oxygenator was removed from the circuit and a second oxygenator was used in the circuit.The event resolved with the exchange.The second oxygenator was primed and used with no issues.The customer did not record any video of the incident.
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Manufacturer's investigation conclusion: although the reported whistling was unable to be conclusively confirmed, functional testing of the returned oxygenator by the manufacturer (eurosets) found that the device was compliant with the technical specifications.The oxygenator was returned to abbott where an initial visual inspection was performed that revealed no obvious abnormalities.The oxygenator was then forwarded to the external manufacturer (eurosets) for investigation.The production documentation for the oxygenator was reviewed by the supplier (eurosets), and it was confirmed that all tests from the production process were compliant with the technical specifications.The production process test is applied to 100% of the devices.A functional test of the oxygenator was performed by eurosets on a test circuit with bovine blood and found that the oxygenator was compliant with the reference values.Eurosets concluded that the technical investigation confirmed that the claimed device was compliant with the technical specification and for that reason they were not able to confirm the complaint.Eurosets communicated that this event will be monitored within the eurosets trend reporting and in case of adverse trends, further investigation and/or corrective actions will be carried out.The eurosets amg pmp instructions for use (ifu) is currently available.Under the list of warnings, the ifu warns that during use, a spare oxygenator must always be available and warns that the device has to be carefully and continuously checked by qualified healthcare professionals throughout the procedure.Under the section titled ¿oxygenator replacement¿, this document states that a spare oxygenator must always be available during perfusion.After 6 hours of use with blood or if particular situations occur, which may lead the person responsible for perfusion to determine the safety of the patient may be compromised (insufficient oxygenator performance, leaks, abnormal blood parameters, etc.), follow the procedure outlined in the ifu for oxygenator replacement.The production documentation for the eurosets oxygenator, lot number 10908708, was reviewed by the external manufacturer (eurosets) and showed that all tests made in the production process were compliant with the technical specifications.No further information was provided.The manufacturer is closing the file on this event.
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