MAUDE Adverse Event Report: MEDTRONIC XOMED INC. NIM® EMG - ENDOTRACHEAL TUBE - NIM FLEX¿; STIMULATOR, NERVE

Model Number	8229965
Medical Device Problem Codes	Deflation Problem (1149); Obstruction of Flow (2423)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/14/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device will not be returned for evaluation, it was reported lost.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
The customer reported "there was (o) hernia blocking the balloon when it was removed".The emg tube was removed without the cuff being fully deflated.There was no patient injury.
Additional Manufacturer Narrative
One opened sample, part number 8229965, from lot number 0212322586 was received for analysis.In an as received condition there was no occlusion of the main tube inside diameter.A syringe was used to inflate the cuff with 15 cc of air.Mild pressure was applied to simulate intubation and in less than 15 seconds the inside diameter began to delaminate and block the airway path which would have resulted in the reported event.Using the 6.5 mm inside diameter as reference, the delamination / separation of the pvc layer measured over 6 mm from the wall which is out of specification.The approximate location / orientation of the occlusion on the inside diameter was centered around the inflation assembly.The tube was deflated with no issue, and the obstruction receded.The device condition was out of specification as it relates to the complaint.If information is provided in the future, a supplemental report will be issued.

• Brand Name: NIM® EMG - ENDOTRACHEAL TUBE - NIM FLEX¿
• Common Device Name: STIMULATOR, NERVE
• Manufacturer (Section D): MEDTRONIC XOMED INC.; 6743 southpoint dr n; jacksonville FL 32216
• MDR Report Key: 7086083
• Report Number: 1045254-2017-00447
• Device Sequence Number: 19199050
• Product Code: ETN
• UDI-Device Identifier: 20643169358793
• UDI-Public: 20643169358793
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 02/02/2018

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
• Operator of Device: Health Professional
• Device Expiration Date: 11/15/2020
• Device Model Number: 8229965
• Device Catalogue Number: 8229965
• Device Lot Number: 0212322586
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/28/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/14/2017
• Supplement Date Received by Manufacturer: 01/10/2018
• Initial Report FDA Received Date: 12/06/2017
• Supplement Report FDA Received Date: 02/02/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1