MAUDE Adverse Event Report: MEDIVANCE, INC. ¿ 1725056 ARCTICGEL PADS; ARCTIC SUN GEL PAD

Catalog Number 318-02

Device Problems Device Alarm System (1012); Inaccurate Flow Rate (1249)

Patient Problems No Consequences Or Impact To Patient (2199); Alteration In Body Temperature (2682)

Event Type  malfunction  

Manufacturer Narrative

The investigation is still in progress.Once the investigation is complete a supplemental report will be filed.The device was not returned.

Event Description

It was reported that there was a low flow alert (alert 02) on the arctic sun device with a neonatal pad.The flow rate was 0.7-1.0l/min, the patient temperature was at the target temperature of 33c, and the water temperature was 29c.Per troubleshooting with ms&s, the nurse disconnected and reconnected the pad, and the flow rate increased from 0.7l/min to 1.0l/min.Per additional information received via ms&s data on 06oct2019, the patient was maintaining the target temperature; however, the nurse was concerned regarding fluctuating water temperatures.The trend indicator and heat generation was discussed.Per follow up with nurse (b)(6) via phone on (b)(6) 2019, the patient remained at target temperature and was rewarming with no further issues.The flow rate continued to fluctuate between 0.9-0.9l/min, and the device continued to alert, but the patient was staying within range of the target temperature.There were no signs of seizure activity or any heat generation.The device will be kept in service.

Event Description

It was reported that there was a low flow alert (alert 02) on the arctic sun device with a neonatal pad.The flow rate was 0.7-1.0l/min, the patient temperature was at the target temperature of 33c, and the water temperature was 29c.Per troubleshooting with ms&s, the nurse disconnected and reconnected the pad, and the flow rate increased from 0.7l/min to 1.0l/min.Per additional information received via ms&s data on 06oct2019, the patient was maintaining the target temperature; however, the nurse was concerned regarding fluctuating water temperatures.The trend indicator and heat generation was discussed.Per follow up with nurse caitlin via phone on 07oct2019, the patient remained at target temperature and was rewarming with no further issues.The flow rate continued to fluctuate between 0.9-0.9l/min, and the device continued to alert, but the patient was staying within range of the target temperature.There were no signs of seizure activity or any heat generation.The device will be kept in service.

Manufacturer Narrative

The device was not returned for evaluation.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 1.Place the patient (1.8 - 4.5 kg; 4.0 - 9.9 lb) on the pad.Avoid placing the patients over the manifolds or other high pressure locations.The rate of temperature change and potentially the final achievable temperature is affected by pad surface area coverage, placement, patient size, and water temperature range.2.The pad surface must be contacting the skin for optimal energy transfer efficiency.A) if desired, the center section of the pad can be wrapped around the patient¿s torso and secured in place using the velcro tabs provided.¿ if this option is in use, ensure that the edges of the pad are away from articulating areas of the body to avoid irritation.¿ place pads to allow for full respiratory excursion.(e.G.Ensure free movement of the chest and abdomen are guaranteed).¿ the pads may be removed and reapplied if necessary.¿ pads should be placed on healthy, clean skin only.3.Due to the small patient size (1.8 - 4.5 kg; 4.0 - 9.9 lb) and the potential for rapid patient temperature change, it is recommended to use the following settings to the arctic sun® temperature management system: ¿ water temperature high limit: =40°c (104°f) ¿ water temperature low limit: =10°c (64.4°f) ¿ control strategy: 2 4.Due to the small patient size (1.8 - 4.5 kg; 4.0 - 9.9 lb) it is recommended to use the patient temperature high and patient temperature low alert settings.5.Place a core patient temperature probe and connect to the arctic sun® temperature management system patient temperature 1 connector for continuous patient temperature feedback.A rectal or esophageal temperature probe is recommended.6.Verify patient core temperature with an independent temperature probe before and at regular intervals during use.7.Attach the pad¿s line connectors to the fluid delivery line manifolds.8.See arctic sun® temperature management system operators manual and help screens for detailed instructions on system use.9.Begin treating the patient.10.If the pad fails to prime or a significant continuous air leak is observed in the pad return line, check the connections, then if needed, replace the leaking pad.Once the pad is primed, assure the steady state flow rate displayed on the control panel is appropriate.The minimum flow rate should be 1.1 l/m.11.When finished, purge water from pad." 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.H3 other text : the device was not returned.

• Brand Name: ARCTICGEL PADS
• Type of Device: ARCTIC SUN GEL PAD
• Manufacturer (Section D): MEDIVANCE, INC. ¿ 1725056; 321 s taylor ave; louisville CO 80027
• MDR Report Key: 9225537
• MDR Text Key: 179273502
• Report Number: 1018233-2019-06701
• Device Sequence Number: 1
• Product Code: DWJ
• Combination Product (y/n): N
• PMA/PMN Number: K142702
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional,other,use
• Type of Report: Initial,Followup
• Report Date: 10/28/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/23/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 318-02
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 10/24/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1