CXD II
Report
- Report Number
- 1423500-2010-02559
- Event Type
- Malfunction
- Date Received
- August 16, 2010
- Date of Event
- July 25, 2010
- Report Date
- July 25, 2010
- Manufacturer
- BAXTER HEALTHCARE - LARGO
- Product Code
- KDJ
- PMA / PMN Number
- K851208
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Occupation
- OTHER
Narratives
(B)(4). SAMPLE AVAILABILITY IS UNKNOWN AT THIS TIME. IF THE SAMPLE IS RECEIVED, A FOLLOW-UP REPORT WILL BE SUBMITTED UPON COMPLETION OF THE EVALUATION.
(B)(4). BAXTER PRODUCT SURVEILLANCE SPOKE WITH THE HOME PATIENT (HP) ON (B)(6) 2010, WHO STATED HE GOT INTO A HURRY WHEN SPIKING WITH THE COMPACT EXCHANGE DEVICE (CXD) AND THAT IS WHEN THE PROBLEM OCCURRED. SINCE THAT TIME, THE HP STATED THAT HE HAS BEEN FOLLOWING THE STEPS AND SLOWLY SPIKING USING THE CXD AND ALL HAS BEEN GOING WELL. THE HP STATED THAT HE IS STILL ON PD THERAPY USING THE HOMECHOICE AND DENIED ANY INJURIES OR ILLNESS. NO SAMPLE WAS RETURNED FOR EVALUATION.
A CUSTOMER CONTACTED BAXTER'S GLOBAL TECHNICAL SERVICE CENTER REQUESTING ASSISTANCE DURING SETUP. THE HOME PATIENT (HP) NEEDED ASSISTANCE WITH THE COMPACT EXCHANGE DEVICE (CXD), BECAUSE THE HP STATED THE SPIKE BROKE OFF WHEN HE TRIED TO CONNECT THE BAG. THE HP WAS NOT SURE HOW IT HAPPENED, BUT HE DIDN'T SEE THE SPIKE ON THE END OF THE LINE. THE HP SEEMED VERY CONFUSED ABOUT SETTING UP THE SUPPLIES. GTS ASSISTED THE HP TO RESTART WITH NEW SUPPLIES. THE HP WOULD CONTINUE WITH SETUP AND CALL BACK WITH ANY QUESTIONS. THERE WAS NO PATIENT INJURY OR MEDICAL INTERVENTION INDICATED AT THE TIME OF THE INITIAL REPORT.
IT WAS REPORTED THAT A PHYSICIAN TRAINED IN THE USE OF THE PROGLIDE DEVICE ATTEMPTED ARTERIOTOMY CLOSURE OF THE RIGHT COMMON FEMORAL ARTERY AFTER AN INTERVENTIONAL PROCEDURE. REPORTEDLY, A KINK WAS FOUND IN THE DISTAL END OF THE SHEATH. THE GUIDE WIRE WAS DIFFICULT TO ADVANCE INTO THE PROGLIDE AND AFTER CONTINUALLY TRYING TO ADVANCE THE GUIDE WIRE, THE GUIDE WIRE PUNCTURING A HOLE THROUGH THE SHEATH CREATING ITS OWN LUMEN. THE TIP OF THE PROGLIDE FOLDED BACK INTO THE PATIENT'S ILIAC, POSSIBLY BECAUSE OF STENOSIS. THE DEVICE WAS REMOVED AND A SECOND PROGLIDE DEVICE WAS USED; HOWEVER, HEMOSTASIS WAS NOT ACHIEVED. HEMOSTASIS WAS ACHIEVED USING MANUAL COMPRESSION FOR APPROXIMATELY 15 MINUTES. THERE WERE NO REPORTED ADVERSE PATIENT EFFECTS. THOUGH REQUESTED, NO ADDITIONAL INFORMATION WAS PROVIDED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1 | CXD II | SET, ADMINISTRATION, FOR PERITONEAL DIALYSIS, DISPOSABLE | KDJ | BAXTER HEALTHCARE - LARGO |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 80 YR |