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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 Problem Contamination of Device Ingredient or Reagent (2901)
Patient Problems Death (1802); Unspecified Infection (1930); Septic Shock (2068); Multiple Organ Failure (3261)
Event Type  Death  
Event Description
In (b)(6) 2013, (b)(6), underwent right knee arthroplasty, using a bair hugger forced air warming device. As a result, it is believed that bacteria contaminated her open surgical site causing a proteus infection. Due to the infection, she suffered substantial injuries, including additional surgical procedures to treat the infection. The infection ultimately led to her death on (b)(6) 2014, due to multiorgan failure and septic shock due to infections. 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"). The mfr of bair hugger faw, 3m corporation, the mfr of bair hugger faw, was notified in writing of the injury by litigation (case: (b)(6)). Fda guidance dated 07/09/2013 provides that such legal documents constitute a "complaint" requiring the mfr to report to the fda, as follows:"2. 11 where will device-related complaints come from? you may receive complaint info from many different sources, including telephone calls or other verbal communication, fax transmissions, written correspondence, sales representative reports, service representative reports, scientific articles (literature), internal analyses, and legal documents. " the mfr, 3m, has failed to report this injury within the mandatory 30 days. 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 (6) 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 pjis 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, her lawyers assert 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 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 pjis, 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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Type of DeviceBAIR HUGGER
Manufacturer (Section D)
MDR Report Key5751646
MDR Text Key48274932
Report NumberMW5063027
Device Sequence Number1
Product Code DWJ
Number of Events Reported1
Summary Report (Y/N)N
Report Source Voluntary
Reporter Occupation
Type of Report Initial
Report Date 06/23/2016
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received06/23/2016
Is this an Adverse Event Report? Yes
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: 06/23/2016 Patient Sequence Number: 1