BEUDAMED
    FDA Adverse Event Death Summary report: N

    PERFUSOR®

    MDR report key: 17692112 · Received September 6, 2023

    Report

    Report Number
    9610825-2023-00406
    Event Type
    Death
    Date Received
    September 6, 2023
    Date of Event
    July 28, 2023
    Report Date
    September 6, 2023
    Manufacturer
    B BRAUN MELSUNGEN AG
    Product Code
    FRN
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FR
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN INTERNAL REPORT NUMBER (B)(4). NOTE: THIS REPORT IS BEING FILED FOR AN ITEM NUMBER THAT IS NOT SOLD IN THE UNITED STATES, HOWEVER SIMILAR ITEMS ARE SOLD IN THE UNITED STATES BY B. BRAUN MEDICAL, INC. PROBLEM: FAULTY FUNCTION FAULTY FUNCTION 1. GENERAL INFORMATION: COMPLAINT: (B)(4). EXAMINATION CARRIED OUT BY: (B)(6). 2. INFORMATION TO THE SAMPLE: 2.1 MODEL: PERFUSOR SPACE. 2.2 ARTICLE NUMBER: 8713030. 2.3 SERIAL NUMBER/BATCH: (B)(6) 2.4 SOFTWARE VERSION: N030005. 2.5 HOURS OF OPERATION: 4411 H. 2.6 FURTHER INFORMATION: N/A. 3. INVESTIGATION RESULTS: 3.1 HISTORY INSPECTION: THE DEVICE HISTORY FILES WERE READ AND ANALYZED. THE HISTORY FILES FROM (B)(6) 2023 (SPECIFIED DATE OF THE INCIDENT, GIVEN FROM THE COSTUMER) WERE INVESTIGATED. AT 13:10 PM A BD PLASTIPAK 50 ML SYRINGE WAS INSERTED. AT 13:11 PM THE PATIENT WEIGHT WAS SET TO 70 KG. THE AMOUNT WAS SET TO 2 MG AND THE VOLUME TO 50 ML. THEN THE DRUG "NAD 40" WAS SELECTED, AND THE RATE WAS SET TO 42 ML/H. AT 14:17 PM THE INFUSION WAS STARTED. AT 14:28 PM THE TOM FUNCTION WAS ACTIVATED, AND THE PUMP WAS SET AS THE MASTER PUMP. AT 15:28 THE INFUSION WAS STOPPED BY THE SYRINGE EMPTY ALARM. UP TO THAT TIME THE DEVICE HAS DELIVERED A VOLUME OF 49,82 ML (ACT. VOLUME INFUSED). AT 15:28 PM THE DEVICE (MASTER) WAS GIVEN THE HINT TO THE OTHER PUMP (SLAVE / SR.NR:589949) TO START THE INFUSION. AT 15:54 PM THE STANDBY MODE WAS ACTIVATED. FURTHERMORE, NO ANOMALIES COULD BE DETECTED INSIDE THE HISTORY FILES. (HISTORY FILES ARE ATTACHED TO THE PC NOTIFICATION). 3.2 VISUAL INSPECTION: A VISUAL INSPECTION WAS PERFORMED. THE COVER CAPS ON THE SCREW PILLARS, AND THE PRODUCTION SEAL ON THE LOWER HOUSING WERE INTACT AND UNDAMAGED. THE DEVICE IS IN A CLEAN STATE AND NO VISIBLE DAMAGED PARTS ARE TO LOCATE. (PICTURES ARE ATTACHED TO THE PC NOTIFICATION). 3.3 FUNCTIONAL INSPECTION: A FUNCTIONAL TEST WAS PERFORMED. THE DEVICE PASSES THE SELF-TEST. A BD PLASTIPAK 50 ML SYRINGE WAS INSERTED, AND THE PUMP IDENTIFIED THE SYRINGE, AND IT COULD BE SELECTED FROM THE MENU. IT WAS POSSIBLE TO PUT THE PUMP IN OPERATION. 3.4 INDIVIDUAL INSPECTION: A DELIVERY ACCURACY MEASUREMENT ACCORDING TO IEC 60601-2-24 WAS ARRANGED. HERE A NOMINAL FLOW RATE OF 5 ML/H WAS CHOSEN. THE ASSESSED MEAN DEVIATION "A" OF THE SECOND OPERATING HOUR WAS MEASURED AND RESULTED IN A VALUE OF +0,54%. ACCURACY OF SET DELIVERY RATE SHOULD BE ± 2 % ACCORDING TO IEC/EN 60601-2-24 (SEE LAB RESULTS ATTACHED TO THE PC-NOTIFICATION). 3.5 DISASSEMBLING: DURING THE INVESTIGATION NO FAULTS COULD BE DETECTED, TO INVESTIGATE THE INSIDE OF THE DEVICE, ONLY THE UPPER HOUSING WAS REMOVED. NO DAMAGE OR SOILING COULD BE FOUND. 3.6 TEST EQUIPMENT: DESCRIPTION: TYP NR.: LAB.-ID.-NR. N/A. N/A. N/A. 3.7 FOR EXAMINATION USED DISPOSABLES: DESCRIPTION: REF.: LOT: BD PLASTIPAK 50 ML. 300865. 2204097. 4. JUDGMENT: 4.1 THE COMPLAINT COULD NOT BE CONFIRMED. SUMMING UP ALL TESTS, THE PERFUSOR SPACE OPERATED WITHIN OUR SPECIFICATION. THE COMPLAINT MALFUNCTION COULD NOT BE REPRODUCED ORE DETECTED INSIDE THE HISTORY FILES. ADDITION INFORMATION: N/A.

    Description of Event or Problem · 0

    AS REPORTED BY THE USER FACILITY INFORMATION BY BBM SALES ORGANIZATION IN FRANCE: "DYSFUNCTION -DEATH." ACCORDING TO THE CUSTOMER: "THE SYRINGE PUMP STOPPED DURING THE INFUSION (NORADRENALINE). THE TREATMENT COULD NOT BE ADMINISTERED, WHICH ACCELERATED THE DEATH OF THE PATIENT (PATIENT AT THE END OF LIFE). INCIDENT ON 28/07 BETWEEN 3 P.M. AND 4:45 P.M. THE CUSTOMER WILL RETURN 6 DEVICES TO US FOR INSPECTION BECAUSE SHE DOES NOT KNOW WITH WHICH THE INCIDENT OCCURRED. FURTHER INFORMATION: WE COULD NOT TO CLEARLY IDENTIFY THE MALFUNCTIONING UNIT, BUT IT WOULD CERTAINLY HAVE BEEN (B)(6) , WHICH PAUSED AT 3.28PM, OR (B)(6) , WHICH PAUSED AT 3.56PM. WE COULD NOT IDENTIFY THE CAUSE OF THIS MALFUNCTION. WE DO NOT KNOW WHETHER AN ALARM WAS TRIGGERED BEFORE THE SYRINGE STOPPED. WHEN THE NURSE ENTERED THE ROOM, THERE WAS NO INDICATOR LIGHT. THE NORADRENALINE SYRINGE WAS PREPARED WITH A CONCENTRATION OF 2 MG IN 50 ML. A CONTINUOUS INFUSION OF NORADRENALINE WAS PLANNED UNTIL THE DECISION OF THE MEDICAL TEAM TO STOP THE ELECTRIC SYRINGE PUMP. HOWEVER, WE FOUND IN OUR SOFTWARE THAT THIS SYRINGE WAS STOPPED AT 3.28PM WITHOUT ANY EXPLANATION. IN VIEW OF THE DOSE OF NORADRENALINE ADMINISTERED TO THE PATIENT, THE INFUSION TIME FOR A 50 ML SYRINGE WAS ESTIMATED AT 1 HOUR 20 MINUTES."

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1454856 PERFUSOR® PUMP, INFUSION FRN B BRAUN MELSUNGEN AG 8713030

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown Death