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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: ARIZANT/3M BAIR HUGGER

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ARIZANT/3M BAIR HUGGER Back to Search Results
Device Problems Nonstandard Device (1420); Microbial Contamination of Device (2303); Contamination of Device Ingredient or Reagent (2901); Temperature Problem (3022)
Patient Problems Staphylococcus Aureus (2058); Post Operative Wound Infection (2446); No Code Available (3191)
Event Date 02/19/2013
Event Type  Injury  
Event Description
This report is submitted regarding injury to (b)(6). On (b)(6) 2013, ms. (b)(6) underwent a right total knee replacement, during which time, it is believed, a 3m bair hugger was used. She was diagnosed with a (b)(6) and was forced to undergo a two-stage revision with the first stage occurring on (b)(6) 2013 for explant of the right knee prosthetic and the second stage occurring on (b)(6) 2014 for fusion of a prosthetic rod. She was also forced to undergo further treatment, including hospitalizations for insertion of picc line for iv antibiotics, skin grafts and blood transfusions, as well as extended home health care. She continues to suffer from permanent and ongoing injuries. Ms. (b)(6), her experts, and lawyers believe that the infection was caused by contamination of the sterile surgical field by the waste heat of the bair hugger forced-air warming system ("faw") used during her surgery; 3m corporation, the mfr of bair hugger faw was notified in writing of the injury by litigation (case (b)(6)). 3m has failed to report this injury within the mandatory 30 days. Ms. (b)(6) and her lawyers assert that the approx 1000 watts of waste heat from bair hugger faw escapes from below the surgical drapes near the floor. From there, it warms the contaminated air normally resident near the floor and forms into convection currents of rising contaminated warm air. The warm air rises alongside the surgical table, easily penetrating operating room ventilation airflow and ending up in the sterile surgical field. This phenomenon has been proved in at least six studies published in top-tier, peer-reviewed medical journals. Many other studies have shown that the concentration of airborne contaminants above the wound positively correlates with the concentration of contaminants in the wound, and also positively correlates with the periprosthetic joint infection ("pji") rate. This leads to the inevitable conclusion that the waste heat from bair hugger faw must be increasing the risk of pji. At least one large outcome study has positively linked this rising waste faw heat to the majority of pji's after total joint replacement surgery. In contrast, there are no outcome studies showing that bair hugger faw is safe in implant surgery. In a separate issue, ms. (b)(6) asserts that 3m has willfully violated the terms of the bair hugger 510 (k). When 510 (k) #12345676 was filed in 2004, the mfr committed to a "hepa" quality inlet filter (99. 97%) or greater filtration efficiency). In fact, the inlet filter of the bair hugger model 505 blower was never hepa and has now been reduced to 62% efficiency without notifying the fda. The result of the poor inlet filtration is that the internal airflow pathways of nearly all bair hugger blowers and hoses are contaminated with growing bacterial colonies. This has been shown in three studies published in top-tier, peer-reviewed medical journals. Further, the high-velocity airflow over the bacterial colonies has been shown to aerosolize bacteria out of the hose and into the operating room air. Since it is impossible to disinfect the internal airflow pathway of the bair hugger 505 blower, a hepa filter should be added to the outlet hose of these blowers to prevent the contamination of the operating room with the bacteria growing inside the blower and hose. Given the catastrophic nature of pji's, it is only prudent for the fda to err on the side of caution. Considering that there are several air-free and waste heat-free pt warming devices on the market today, any product that increases the risk of a pji should not be allowed in orthopedic surgery.
 
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Brand NameBAIR HUGGER
Type of DeviceBAIR HUGGER
Manufacturer (Section D)
ARIZANT/3M
MDR Report Key5694379
MDR Text Key46447117
Report NumberMW5062598
Device Sequence Number1
Product Code DWJ
Reporter Country CodeUS
Number of Events Reported1
Summary Report (Y/N)N
Report Source Voluntary
Reporter Occupation
Type of Report Initial
Report Date 05/27/2016
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received05/27/2016
Is this an Adverse Event Report? No
Is this a Product Problem Report? No
Device Operator
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? No Answer provided
Was the Report Sent to FDA?
Event Location No Information
Was Device Evaluated by Manufacturer? No Answer Provided
Is the Device Single Use? No Answer Provided
Is This a Reprocessed and Reused Single-Use Device?
Type of Device Usage

Patient Treatment Data
Date Received: 05/27/2016 Patient Sequence Number: 1
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