MAUDE Adverse Event Report: INOVO INC SMARTDOSE GAS CONSERVER, 310G

Model Number	CTOX-MN02
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device is used to provide supplemental oxygen to patient with compromised respiratory function.It is not intended to be used as a life sustaining device.It was stated that the device was in conserve mode, which means the device producing a bolus of supplemental oxygen as the patient inhales.If the patient's breathing was shallow after the syncopal episode, there may not have been enough negative pressure for the device to deliver the oxygen at conserve mode.Once the device oxygen flow function was switched to continuous flow a steady flow of oxygen was delivered to the patient.It was stated that the patient was easily aroused and regained consciousness spontaneously with no medical intervention.These factors conclude that the patient did not suffer a loss of consciousness, but rather a syncopal episode.Syncopal episodes are a temporary loss of consciousness and posture, described as "fainting" or "passing out".It usually related to temporary insufficient blood flow to the brain.It most often occurs when the blood pressure is too low (hypotension) and the heart does not pump a normal supply of oxygen to the brain.If the patient had lost consciousness due to decreased oxygen to the brain (hypoxia), the patient would have needed more aggressive respiratory treatment than just simply switching the device to continuous flow mode.Syncope can be caused by neurological disorder, orthostatic hypotension or a side effect of medications.It can be concluded that the patient's temporary loss of consciousness was caused by some factor other than the amount of oxygen given or not given by the device.With the information provided, there is insufficient evidence to determine a causal relationship between the alleged in the complaint and the patient's syncopal episode; however, because a patient reportedly had a syncopal episode associated with an inovo device, the event was reported to the fda.The device has not yet been received for testing.Inovo, inc.Will submit a supplemental report if the device is received and after inovo, inc.Service/repair facility concludes its investigation.Note that this mdr was previously submitted on 02/03/2017 and is being re-submitted because it was not fully processed or received by fda due to an error.
Event or Problem Description
It was reported that the conserver was not producing sufficient oxygen.Additional information obtained from the delivery driver who spoke with the patient's caregiver is as follows: the caregiver stated that she walked into the room and found the patient had a syncopal episode.The caregiver stated that all the lights on the conserver were on and the device was in the conserve mode.She stated that she changed the device to continous flow and the patient regained consciousness.There was no reported device malfunction and it could not be determined if the patient regained consciousness because the device was switched to continous flow or if the symptoms resolved spontaneously.There was no additional reported medical interventions performed and the patient did not seek medical attention for the issue described.It was noted by the delivery driver that the tag with the serial number had faded as if a chemical cleaning agent was used on the device.No additional information provided.

• Brand Name: SMARTDOSE GAS CONSERVER, 310G
• Common Device Name: CONSERVER
• Manufacturer (Section D): INOVO INC; 401 leonard blvd north; lehigh acres FL 33971
• MDR Report Key: 6603063
• Report Number: 1062191-2017-00007
• Device Sequence Number: 13653622
• Product Code: NFB
• UDI-Device Identifier: 00814470020075
• UDI-Public: 00814470020075
• Combination Product (Y/N): N
• Initial Reporter State: OK
• Initial Reporter Country: US
• PMA/510(K) Number: K090421
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,consum
• Initial Reporter Occupation: Respiratory Therapist
• Type of Report: Initial
• Report Date (Section B): 01/17/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Lay User/Patient
• Device Model Number: CTOX-MN02
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/09/2017
• Initial Report FDA Received Date: 05/31/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other