MAUDE Adverse Event Report: MEDLINE INDUSTRIED LP MEDLINE; ANESTHESIA CIRCUIT ADULT

Catalog Number	DYNJAA0408A
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/07/2026
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
It reported it was reported that the gas sample port was broken off the filtered hme.There are no reports of death, serious injury, medical intervention, or follow up care.It has been determined that the reported event could cause or contribute to serious injury if it were to occur again.In an abundance of caution, this is a reportable event.If additional information becomes available this report will be reopened and reevaluated.
Event or Problem Description
It was reported that the gas sample port was broken off the filtered hme.

• Brand Name: MEDLINE
• Common Device Name: ANESTHESIA CIRCUIT ADULT
• Manufacturer (Section D): MEDLINE INDUSTRIED LP; three lakes dr; northfield IL 60093 2753
• Manufacturer Contact: leann gifford ; three lakes dr; northfield, IL 60093-2753
• MDR Report Key: 25559786
• Report Number: 1417592-2026-02598
• Device Sequence Number: 16024121
• Product Code: CAI
• UDI-Device Identifier: 10198459116872
• UDI-Public: 10198459116872
• Combination Product (Y/N): Y
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K925217
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 06/18/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Expiration Date: 05/31/2026
• Device Catalogue Number: DYNJAA0408A
• Device Lot Number: 24JBI372
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/27/2026
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/07/2026
• Initial Report FDA Received Date: 06/19/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 10/18/2024
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown