| Catalog Number |
F00012970 |
| Medical Device Problem Code |
Obstruction of Flow (2423)
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| Health Effect - Clinical Code |
Hemorrhage/Blood Loss/Bleeding (1888)
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| Date of Event |
03/04/2026
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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The plant investigation is in process.A supplemental mdr will be submitted upon completion of this activity. .
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Event or Problem Description
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A user facility¿s registered nurse (rn) reported that a fresenius coral dialyzer did not clear air during priming resulting in an ¿air detector¿ alarm on the machine during a patient¿s hemodialysis (hd) treatment and subsequent blood loss.Upon follow up, the rn said that immediately after the initiation of the patient¿s hemodialysis (hd) treatment a fresenius 2008t machine displayed an air detector alarm.It was determined at that time that the dialyzer had clotted.A fresenius bloodline was in use.The patient¿s estimated blood loss (ebl) was approximately 300ml.It is unknown how many units of heparin were in use.It is unknown how much prime solution was used.The dialyzer was rotated and tapped during priming.The patient was restarted on a new machine and treatment completed successfully with new supplies.There was no patient serious injury or medical intervention required as a result of this event.The complaint device was reported to be available to be returned to the manufacturer for evaluation.
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Event or Problem Description
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A user facility's registered nurse (rn) reported that a fresenius coral dialyzer did not clear air during priming resulting in an "air detector" alarm on the machine during a patient¿s hemodialysis (hd) treatment and subsequent blood loss.Upon follow up, the rn said that immediately after the initiation of the patient¿s hemodialysis (hd) treatment a fresenius 2008t machine displayed an air detector alarm.It was determined at that time that the dialyzer had clotted.A fresenius bloodline was in use.The patient¿s estimated blood loss (ebl) was approximately 300 ml.It is unknown how many units of heparin were in use.It is unknown how much prime solution was used.The dialyzer was rotated and tapped during priming.The patient was restarted on a new machine and treatment completed successfully with new supplies.There was no patient serious injury or medical intervention required as a result of this event.The complaint device was reported to be available to be returned to the manufacturer for evaluation.
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Additional Manufacturer Narrative
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Plant investigation: the complaint device was returned to the manufacturer for physical evaluation.Visual examination and a tightness test of the sample confirmed the reported failure due clotting in the closed fibers.A production records review was performed on the reported lot.An investigation of the device history records (dhr) was conducted by the manufacturer.There was no indication of product nonacceptance, deviation, nonconformance, rework, labeling or process control failure during the manufacturing process which could be associated with the reported event.The lot met all release criteria.The investigation into the complaint was able to confirm the reported event.
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Search Alerts/Recalls
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