|
Investigation: the run data file (rdf) was analyzed for this event.Review of the run data file shows there was a total of 6 occurrences between the alarms ¿cells were detected in plasma line from centrifuge¿ & ¿system continued to detect cells in plasma line from centrifuge¿.In tpe, the system generates these alarms when the rbc detector signals indicate a value greater than 1.5, indicating a darker than expected plasma was detected in the plasma line.The alarm may occur for various reasons including small air bubble(s) at the rbc detector, the entered patient hematocrit was too low leading to a high interface and spill over, or a shift in the patient fluid balance caused the actual patient hematocrit to increase leading to a spill over.In response to this alarm, it is suggested to increase the patient hct by 3% points for up to 9% points.In this procedure, the operator increased the input patient hct from 34% to 39% by 4 minutes into the procedure and the procedure was discontinued at 6.5 minutes.In tpe, the system will use the input patient data to control the position of the interface.If the input patient hct is lower than actual, the system will run the plasma pump faster assuming there is more plasma to remove, causing the cell interface to rise in the channel connector.It is possible the entered patient hct needed to be increased further and kept at the higher value to maintain the interface at the correct height.Analysis of the run data file cannot confirm if this contributed to the reported issue.Signals in the run data file show the procedure started at an inlet flow rate of 120 ml/min and decreased to 100 ml/min shortly after the procedure started.This was decreased further to 40 ml/min at 1 minute into the procedure.Higher flow rates can reduce the packing factor at which the device is running at, making it harder to pack cells in the centrifuge and possibly causing spillover that results in pink plasma.Analysis of the run data file cannot confirm if this contributed to the reported issue.Aim images were not available for review at the time of performing this analysis.Signals in the run data file do not show the occurrence of any aim alarms indicating a higher-than-expected interface during the procedure.Analysis of the run data file is not able to confirm the occurrence of hemolysis during this procedure.The device was found to be operating as intended with the appropriate alarms raised and all safety systems remaining in place.There were no issues identified with the device.Lot number, manufacture date and expiry date are not available at this time.Investigation is in process, a follow-up report will be provided.
|