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A facility reported that on insertion of a new external ventricular drainage (evd), the traumacath, 35cm (ins8420) was noted to have a crack in it.Patient impact was unknown, and there was surgical delay; however, the duration of the delay is unknown.Unfortunately after following up with the team and the site, no further information is available for this case as it occurred last year, and the hospital does not have any notes on the issue to refer to.
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Updated fields: d4, d9, g3, g6, h2, h3, h4, h6, h11.The traumacath, 35cm (ins8420) was returned for evaluation: device history record (dhr) - the dhr was reviewed and no anomaly was observed during its manufacturing, packaging, and inspection process that could be related to the reported condition.Failure analysis - the visual inspection of the returned product shows blood residues/debris (clots and stains) inside the catheter; therefore, the product had been used at the field.The upper part of the catheter (proximal to surgeon) was observed to have been torn off.The breakage was uneven giving the appearance of broken-off, not cut.The missing portion (about 0.5 inch) was not returned.The nominal measurement for the catheter length from the tip is 14 inches, but the returned catheter approximately measured 13 5/8inches (at the longest side of the tear).Further evaluation revealed that there was a tear just below the 7 cm mark (approx.2 ¾ inches from the distal tip) on the catheter, and at the end of the torn part there are stress marks that suggest the tube was pulled beyond its breaking point.Root cause - the complaint is confirmed via the inspection.Based on the torn condition of the catheter at two (2) different places, it is concluded that the catheter was submitted to excessive force at the field.No capa escalation is required since the condition observed on the returned product suggests that the catheter tubing was submitted to excessive force at the field.There are controls during the manufacturing process to prevent and detect the reported condition.Also, upon review of integra¿s complaint system from june 2024 to august 2025, no additional complaints related to the reported have been identified for catalog ins8420 traumacath, 35cm, and no complaint trend signal has been identified for this reported condition.This will be monitored and trended going forward.At present, we consider this complaint to be closed.
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