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| Catalog Number 5000-00-00 |
| Device Problems
Device Displays Incorrect Message (2591); Temperature Problem (3022)
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| Patient Problem
Therapeutic Effects, Unexpected (2099)
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Event Type
malfunction
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Manufacturer Narrative
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The investigation is still in progress.Once the investigation is complete a supplemental report will be filed.The information provided by bard represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bard.
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Event Description
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It was reported that the device displayed an alert 113 every 30 minutes throughout the day shift.The target temperature was 34.8 c, the patient's temperature was 34.1 c, and water temperature was 31 c.Per troubleshooting, it was determined that the heater was functional but the chiller was not.Therapy was interrupted in order to put the patient onto a second device.Therapy resumed on the second device with no further issues.
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Manufacturer Narrative
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The reported event was confirmed.The device was evaluated by the facility's biomed.The root cause of the reported issue of an alert 113 was isolated to a mixing pump failure.The mixing pump failed to circulate water from the main circulation tank to the chiller tank to be cooled.This can be caused by either the pump head or pump motor.This failure resulted in the water level not rising in the chiller tank to properly overflow chilled water back into the main circulation tank.This failure of the mixing pump causes the reduced water temperature control, the eventual alert 113, and prevents chilled water from being provided to the patient therapy pads for proper patient temperature management.The mixing pump will be replaced which will correct the reported issue.The device may be sent back to dymax for further evaluation.In the event that the device is received, this record will be reopened to complete a sampled investigation.The device history record was reviewed and found nothing that could have caused or contributed to the reported event.The instructions for use state the following: "the arctic sun temperature management system is a thermal regulating system, indicated for monitoring and controlling patient temperature.Warnings and cautions warnings do not use the arctic sun temperature management system in the presence of flammable agents because an explosion and/or fire may result.Do not use high frequency surgical instruments or endocardial catheters while the arctic sun temperature management system is in use.There is a risk of electrical shock and hazardous moving parts.There are no user serviceable parts inside.Do not remove covers.Refer servicing to qualified personnel.Power cord has a hospital grade plug.Grounding reliability can only be achieved when connected to an equivalent receptacle marked ¿hospital use¿ or ¿hospital grade¿.When using the arctic sun temperature management system, note that all other thermal conductive systems, such as water blankets and water gels, in use while warming or cooling with the arctic sun temperature management system may actually alter or interfere with patient temperature control.Do not place arcticgel pads over transdermal medication patches as warming can increase drug delivery, resulting in possible harm to the patient.Cautions this product is to be used by or under the supervision of trained, qualified medical personnel.Federal law (usa) restricts this device to sale, by or on the order of a physician.Use only distilled or sterile water.The use of other fluids will damage the arctic sun temperature management system.When moving the arctic sun temperature management system always use the handle to lift the controller over an obstacle to avoid over balancing.The patient bed surface should be located between 30 and 60 inches (75 cm and 150 cm) above the floor to ensure proper flow and minimize risk of leaks.The clinician is responsible to determine the appropriateness of custom parameters.When the system is powered off, all changes to parameters will revert to the default unless the new settings have been saved as new defaults in the advanced setup screen.For small patients (=30 kg) it is recommended to use the following settings: water temperature high limit =40°c (104°f); water temperature low limit =10°c (50 °f); control strategy =2.The operator must continuously monitor patient temperature when using manual control and adjust the temperature of the water flowing through the pads accordingly.Patient temperature will not be controlled by the arctic sun temperature management system in manual control.Due to the systems high efficiency, manual control is not recommended for long duration use.The operator is advised to use the automatic therapy modes (e.G.Control patient, cool patient, rewarm patient) for automatic patient temperature monitoring and control.The arctic sun temperature management system will monitor and control patient core temperature based on the temperature probe attached to the system.The clinician is responsible for correctly placing the temperature probe and verifying the accuracy and placement of the patient probe at the start of the procedure.Medivance supplies temperature simulators (fixed value resistors) for testing, training and demonstration purposes.Never use this device, or other method, to circumvent the normal patient temperature feedback control when the system is connected to the patient.Doing so exposes the patient to the hazards associated with severe hypo- or hyper-thermia.Medivance recommends measuring patient temperature from a second site to verify patient temperature.Medivance recommends the use of a second patient temperature probe connected to the arctic sun temperature management system temperature 2 input as it provides continuous monitoring and safety alarm features.Alternatively, patient temperature may be verified periodically with independent instrumentation.The displayed temperature graph is for general information purposes only and is not intended to replace standard medical record documentation for use in therapy decisions.Patient temperature will not be controlled and alarms are not enabled in stop mode.Patient temperature may increase or decrease with the arctic sun temperature management system in stop mode.Carefully observe the system for air leaks before and during use.If the pads fail to prime or a significant continuous air leak is observed in the pad return line, check connections.If needed, replace the leaking pad.Leakage may result in lower flow rates and potentially decrease the performance of the system.The arctic sun temperature management system is for use only with the arcticgel pads.The arcticgel pads are only for use with the arctic sun temperature management systems.The arcticgel pads are non-sterile for single patient use.Do not reprocess or sterilize.If used in a sterile environment, pads should be placed according to the physician request, either prior to the sterile preparation or sterile draping.Arcticgel pads should not be placed on a sterile field.Use pads immediately after opening.Do not store pads once the kit has been opened.Do not place arcticgel pads on skin that has signs of ulceration, burns, hives, or rash.While there are no known allergies to hydrogel materials, caution should be exercised with any patient who has a history of skin allergies or sensitivities.Do not allow circulating water to contaminate the sterile field when patient lines are disconnected.The water content of the hydrogel affects the pad adhesion to the skin and conductivity, and therefore, the efficiency of controlling patient temperature.Periodically check that pads remain moist and adherent.Replace pads when the hydrogel no longer uniformly adheres to the skin.Replacing pads at least every 5 days is recommended.Do not puncture the arcticgel pads with sharp objects.Punctures will result in air entering the fluid pathway and may reduce performance.If accessible, examine the patient skin under the arcticgel pads often, especially those at higher risk of skin injury.Skin injury may occur as a cumulative result of pressure, time and temperature.Do not place bean bag or other firm positioning devices under the arcticgel pads.Do not place positioning devices under the pad manifolds or patient lines.The rate of temperature change and potentially the final achievable patient temperature is affected by many factors.Treatment application, monitoring and results are the responsibility of the attending physician.If the patient does not reach target temperature in a reasonable time or the patient is not able to be maintained at the target temperature, the skin may be exposed to low or high water temperatures for an extended period of time which may increase the risk for skin injury.Ensure that pad sizing/coverage and custom parameter settings are correct for the patient and treatment goals, water flow is greater than or equal to 2.3 liters per minute and the patient temperature probe is in the correct place.For patient cooling, ensure environmental factors such as excessively hot rooms, heat lamps, and heated nebulizers are eliminated and patient shivering is controlled.Otherwise, consider increasing minimum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.For patient warming, consider decreasing maximum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.Due to underlying medical or physiological conditions, some patients are more susceptible to skin damage from pressure and heat or cold.Patients at risk include those with poor tissue perfusion or poor skin integrity due to diabetes, peripheral vascular disease, poor nutritional status, steroid use or high dose vasopressor therapy.If warranted, use pressure relieving or pressure reducing devices under the patient to protect from skin injury.Do not allow urine, antibacterial solutions or other agents to pool underneath the arcticgel pads.Urine and antibacterial agents can absorb into the pad hydrogel and cause chemical injury and loss of pad adhesion.Replace pads immediately if these fluids come into contact with the hydrogel.Do not place arcticgel pads over an electrosurgical grounding pad.The combination of heat sources may result in skin burns.If needed, place defibrillation pads between the arcticgel pads and the patient¿s skin.Carefully remove arcticgel pads from the patient¿s skin at the completion of use.Discard used arcticgel pads in accordance with hospital procedures for medical waste.The usb data port is to be used only with a standalone usb flash drive.Do not connect to another mains powered device during patient treatment.Users should not use cleaning or decontamination methods different from those recommended by the manufacturer without first checking with the manufacturer that the proposed methods will not damage the equipment.Do not use bleach (sodium hypochlorite) as it may damage the system.Medivance will not be responsible for patient safety or equipment performance if the procedures to operate, maintain, modify or service the medivance arctic sun temperature management system are other than those specified by medivance.Anyone performing the procedures must be appropriately trained and qualified.Reviewed baw2800172, revision 1 (arctic sun 5000 operator's manual addendum), which states the following: the arctic sun temperature management system is not intended for use in the operating room environment." (b)(4).The device was evaluated by a biomedical technician at the complainant's facility.
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Event Description
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It was reported that the device displayed an alert 113 every 30 minutes throughout the day shift.The target temperature was 34.8c, the patient's temperature was 34.1c, and water temperature was 31c.Per troubleshooting, it was determined that the device was able to heat but not able to cool.Therapy was interrupted in order to put the patient onto a second device.Therapy resumed on the second device with no further issues.
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Manufacturer Narrative
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The reported event was confirmed.The root cause of the reported issue of an alert 113 was isolated to a mixing pump failure.The mixing pump failed to circulate water from the main circulation tank to the chiller tank to be cooled.This can be caused by either the pump head or pump motor.This failure resulted in the water level not rising in the chiller tank to properly overflow chilled water back into the main circulation tank.This failure of the mixing pump caused the reduced water temperature control, the eventual alert 113, and prevented chilled water from being provided to the patient therapy pads for proper patient temperature management.The mixing pump was replaced.The device went through the preventative maintenance program.The heater, drain valves, and manifold o-rings were replaced.The circulation pump was rebuilt.Temperature cable was tested with patient temperature simulator keys and passed.No signs of damage to cord.Control panel passed current leakage test.Shock sensor installed, loctite applied to casters, graphic software updated from (b)(4), coin cell battery replaced due to age, and chiller ground stud updated.Device passed acats and electrical safety tests.The as5000 was subsequently inspected and tested by bes-dymax in accordance with bes-dymax standard processes and procedures, after service, was found to fully comply with all requirements and specifications.The device history record was reviewed and found nothing that could have caused or contributed to the reported event.The instructions for use state the following: "the arctic sun® temperature management system is a thermal regulating system, indicated for monitoring and controlling patient temperature.Warnings and cautions: warnings; do not use the arctic sun® temperature management system in the presence of flammable agents because an explosion and/or fire may result.Do not use high frequency surgical instruments or endocardial catheters while the arctic sun® temperature management system is in use.There is a risk of electrical shock and hazardous moving parts.There are no user serviceable parts inside.Do not remove covers.Refer servicing to qualified personnel.Power cord has a hospital grade plug.Grounding reliability can only be achieved when connected to an equivalent receptacle marked ¿hospital use¿ or ¿hospital grade¿.When using the arctic sun® temperature management system, note that all other thermal conductive systems, such as water blankets and water gels, in use while warming or cooling with the arctic sun® temperature management system may actually alter or interfere with patient temperature control.Do not place arcticgel¿ pads over transdermal medication patches as warming can increase drug delivery, resulting in possible harm to the patient.Cautions: this product is to be used by or under the supervision of trained, qualified medical personnel.Federal law (usa) restricts this device to sale, by or on the order of a physician.Use only distilled or sterile water.The use of other fluids will damage the arctic sun® temperature management system.When moving the arctic sun® temperature management system always use the handle to lift the controller over an obstacle to avoid over balancing.The patient bed surface should be located between 30 and 60 inches (75 cm and 150 cm) above the floor to ensure proper flow and minimize risk of leaks.The clinician is responsible to determine the appropriateness of custom parameters.When the system is powered off, all changes to parameters will revert to the default unless the new settings have been saved as new defaults in the advanced setup screen.For small patients (=30 kg) it is recommended to use the following settings: water temperature high limit =40°c (104°f); water temperature low limit =10°c (50 °f); control strategy =2.The operator must continuously monitor patient temperature when using manual control and adjust the temperature of the water flowing through the pads accordingly.Patient temperature will not be controlled by the arctic sun® temperature management system in manual control.Due to the systems high efficiency, manual control is not recommended for long duration use.The operator is advised to use the automatic therapy modes (e.G.Control patient, cool patient, rewarm patient) for automatic patient temperature monitoring and control.The arctic sun® temperature management system will monitor and control patient core temperature based on the temperature probe attached to the system.The clinician is responsible for correctly placing the temperature probe and verifying the accuracy and placement of the patient probe at the start of the procedure.Medivance supplies temperature simulators (fixed value resistors) for testing, training and demonstration purposes.Never use this device, or other method, to circumvent the normal patient temperature feedback control when the system is connected to the patient.Doing so exposes the patient to the hazards associated with severe hypo- or hyper-thermia.Medivance recommends measuring patient temperature from a second site to verify patient temperature.Medivance recommends the use of a second patient temperature probe connected to the arctic sun® temperature management system temperature 2 input as it provides continuous monitoring and safety alarm features.Alternatively, patient temperature may be verified periodically with independent instrumentation.The displayed temperature graph is for general information purposes only and is not intended to replace standard medical record documentation for use in therapy decisions.Patient temperature will not be controlled and alarms are not enabled in stop mode.Patient temperature may increase or decrease with the arctic sun® temperature management system in stop mode.Carefully observe the system for air leaks before and during use.If the pads fail to prime or a significant continuous air leak is observed in the pad return line, check connections.If needed, replace the leaking pad.Leakage may result in lower flow rates and potentially decrease the performance of the system.The arctic sun® temperature management system is for use only with the arcticgel¿ pads.The arcticgel¿ pads are only for use with the arctic sun® temperature management systems.The arcticgel¿ pads are non-sterile for single patient use.Do not reprocess or sterilize.If used in a sterile environment, pads should be placed according to the physician request, either prior to the sterile preparation or sterile draping.Arcticgel¿ pads should not be placed on a sterile field.Use pads immediately after opening.Do not store pads once the kit has been opened.Do not place arcticgel¿ pads on skin that has signs of ulceration, burns, hives, or rash.While there are no known allergies to hydrogel materials, caution should be exercised with any patient who has a history of skin allergies or sensitivities.Do not allow circulating water to contaminate the sterile field when patient lines are disconnected.The water content of the hydrogel affects the pad adhesion to the skin and conductivity, and therefore, the efficiency of controlling patient temperature.Periodically check that pads remain moist and adherent.Replace pads when the hydrogel no longer uniformly adheres to the skin.Replacing pads at least every 5 days is recommended.Do not puncture the arcticgel¿ pads with sharp objects.Punctures will result in air entering the fluid pathway and may reduce performance.If accessible, examine the patient skin under the arcticgel¿ pads often, especially those at higher risk of skin injury.Skin injury may occur as a cumulative result of pressure, time and temperature.Do not place bean bag or other firm positioning devices under the arcticgel¿ pads.Do not place positioning devices under the pad manifolds or patient lines.The rate of temperature change and potentially the final achievable patient temperature is affected by many factors.Treatment application, monitoring and results are the responsibility of the attending physician.If the patient does not reach target temperature in a reasonable time or the patient is not able to be maintained at the target temperature, the skin may be exposed to low or high water temperatures for an extended period of time which may increase the risk for skin injury.Ensure that pad sizing / coverage and custom parameter settings are correct for the patient and treatment goals, water flow is greater than or equal to 2.3 liters per minute and the patient temperature probe is in the correct place.For patient cooling, ensure environmental factors such as excessively hot rooms, heat lamps, and heated nebulizers are eliminated and patient shivering is controlled.Otherwise, consider increasing minimum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.For patient warming, consider decreasing maximum water temperature, modifying target temperature to an attainable setting or discontinuing treatment.Due to underlying medical or physiological conditions, some patients are more susceptible to skin damage from pressure and heat or cold.Patients at risk include those with poor tissue perfusion or poor skin integrity due to diabetes, peripheral vascular disease, poor nutritional status, steroid use or high dose vasopressor therapy.If warranted, use pressure relieving or pressure reducing devices under the patient to protect from skin injury.Do not allow urine, antibacterial solutions or other agents to pool underneath the arcticgel¿ pads.Urine and antibacterial agents can absorb into the pad hydrogel and cause chemical injury and loss of pad adhesion.Replace pads immediately if these fluids come into contact with the hydrogel.Do not place arcticgel¿ pads over an electrosurgical grounding pad.The combination of heat sources may result in skin burns.If needed, place defibrillation pads between the arcticgel¿ pads and the patient¿s skin.Carefully remove arcticgel¿ pads from the patient¿s skin at the completion of use.Discard used arcticgel¿ pads in accordance with hospital procedures for medical waste.The usb data port is to be used only with a standalone usb flash drive.Do not connect to another mains powered device during patient treatment.Users should not use cleaning or decontamination methods different from those recommended by the manufacturer without first checking with the manufacturer that the proposed methods will not damage the equipment.Do not use bleach (sodium hypochlorite) as it may damage the system.Medivance will not be responsible for patient safety or equipment performance if the procedures to operate, maintain, modify or service the medivance arctic sun® temperature management system are other than those specified by medivance.Anyone performing the procedures must be appropriately trained and qualified.Reviewed baw2800172, revision 1 (arctic sun 5000 operator's manual addendum), which states the following: the arctic sun® temperature management system is not intended for use in the operating room environment." (b)(4).
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Event Description
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It was reported that the device displayed an alert 113 every 30 minutes throughout the day shift.The target temperature was 34.8c, the patient's temperature was 34.1c, and water temperature was 31c.Per troubleshooting, it was determined that the device was able to heat, however unable to cool.Therapy was interrupted in order to put the patient onto a second device.Therapy resumed on the second device with no further issues.
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Search Alerts/Recalls
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