It was reported that while the patient was cooling, the arctic sun device started alerting low flow.The patient's temperature was 34c, the water temperature was 15.7c, the flow rate was 1.6lpm, and the trend indicator was neutral.The event log showed that there were multiple alert 02's.The nurse stated that there were only 2 chest pads on the patient as the patient had surgery for decreased blood flow to the legs.The nurse was directed to add the other 2 pads to the manifold and lay them to the side to increase the flow rate.The nurse stated that she could only find one of the leg pads and the flow rate increased to 2.0lpm.The patient had not reached cooling target temperature and paralytics were administered.
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It was reported that while the patient was cooling, the arctic sun device started alerting low flow.The patient's temperature was 34c, the water temperature was 15.7c, the flow rate was 1.6lpm, and the trend indicator was neutral.The event log showed that there were multiple alert 02's.The nurse stated that there were only 2 chest pads on the patient as the patient had surgery for decreased blood flow to the legs.The nurse was directed to add the other 2 pads to the manifold and lay them to the side to increase the flow rate.The nurse stated that she could only find one of the leg pads and the flow rate increased to 2.0lpm.The patient had not reached cooling target temperature and paralytics were administered.
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The reported event could not be confirmed as no sample was returned for evaluation.A potential failure mode could be 'poor flow' with a potential root cause of 'incorrect setup causing pad lines occlusion, e.G.Kinking.¿ the lot number is unknown; therefore, the device history record could not be reviewed.The instructions for use were found adequate and state the following: "directions for use 1.Arcticgel¿ pads are only for use with an arctic sun® temperature management system control module.See operators manual for detailed instructions on system use.2.Select the proper number, size and style pad for the patient size and clinical indication.However, the rate of temperature change and potentially the final achievable temperature is affected by pad surface area, patient size, pad placement and water temperature range.Best system performance will be achieved by using the maximum number and largest size pads.3.For patient comfort, the pads may be prewarmed using water temperature control mode (manual) prior to application.4.Place the pads on healthy, clean skin only.Remove any creams or lotions from patient¿s skin before pad application.Remove the release liner from each pad and apply to the appropriate area.The pads may be overlapped or folded adhesive-to-adhesive to achieve proper placement.The pads may be removed and reapplied if necessary.The pad surface must be contacting the skin for optimal energy transfer efficiency.Place pads to allow for full respiratory excursion.5.Attach the pad¿s line connectors to the patient line manifolds.Begin circulating water through the pads using either patient temperature control mode (automatic) or water temperature control mode (manual).If the pads fail to prime or a significant continuous air leak is observed in the pad return line, check connections, then if needed replace the leaking pad.6.Once the pads are primed, assure the flow rate displayed on the control panel is greater than 2.3 liters per minute, which is the minimum flow rate for a full pad kit.7.When finished, empty water from pads.Cold temperature increases the adhesiveness of the hydrogel.For ease of removal, leave pads on the patient for approximately 15 minutes to allow the hydrogel to warm.Slowly remove pads from the patient and discard." h11:section a through f - the information provided by bd 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 bd.
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