BEUDAMED
    FDA Adverse Event Injury Summary report: N

    RENAL - DISPOSABLE

    MDR report key: 1961971 · Received January 15, 2011

    Report

    Report Number
    1423500-2011-00685
    Event Type
    Injury
    Date Received
    January 15, 2011
    Date of Event
    December 1, 2010
    Report Date
    December 21, 2010
    Product Code
    KDJ
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IN
    Reporter Occupation
    NURSE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE DEVICES INVOLVED IN THE INCIDENT WERE UNKNOWN. AS THE DATE OF ONSET OF THIS PERITONITIS EPISODE IS UNKNOWN AND PATIENTS DISCARD SUPPLIES AFTER EACH THERAPY, THE SAMPLE WAS NOT REQUESTED. A 510(K) NUMBER WILL NOT BE PROVIDED IN THE EMDR AS THE PRODUCT CODE AND LOT NUMBER ARE UNKNOWN. SINCE THE LOT NUMBER IS UNKNOWN, NO BATCH REVIEW WILL BE PERFORMED. BAXTER HAS RECEIVED SIMILAR REPORTS FOR THE REPORTED PROBLEM. BAXTER WILL CONTINUE TO MONITOR SIMILAR REPORTS TO DETERMINE IF FURTHER ACTION IS REQUIRED.

    Description of Event or Problem · 1

    THIS IS A SPONTANEOUS REPORT BY A BAXTER EMPLOYED NURSE FROM (B)(6) OF PERITONITIS IN A (B)(6) MALE PATIENT COINCIDENT WITH DIANEAL PD2 ULTRABAG THERAPY. ON (B)(6) 2010, THE PATIENT BEGAN TREATMENT WITH DIANEAL PD2 ULTRABAG 2.5%, MOST RECENT LOT NUMBER 1010080 (DOSE AND FREQUENCY NOT REPORTED) INTRAPERITONEALLY (IP) FOR PERITONEAL DIALYSIS (PD). ON (B)(6) 2010, THE PATIENT BEGAN TREATMENT WITH DIANEAL PD2 ULTRABAG 4.25%, MOST RECENT LOT NUMBER 1010038 (DOSE AND FREQUENCY NOT REPORTED) IP FOR PD. ON (B)(6) 2010 THE PATIENT EXPERIENCED PERITONITIS. HOSPITALIZATION WAS NOT REQUIRED. ON AN UNREPORTED DATE, THE PATIENT BEGAN TREATMENT WITH TOBRAMYCIN 40 MG INTRAPERITONEALLY (IP) AND BIOPIPER 2.25 GM INTRAVENOUSLY (IV) TWICE DAILY. THE ROOT CAUSE OF THE PERITONITIS WAS NOT REPORTED. THE OUTCOME OF THE PERITONITIS WAS REPORTED AS RESOLVING. DIANEAL THERAPY CONTINUED. CAUSALITY ASSESSMENT FOR THE ADVERSE EVENT OF PERITONITIS TO DIANEAL THERAPY WAS NOT REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 RENAL - DISPOSABLE SET, ADMINISTRATION, FOR PERITONEAL DIALYSIS, DISPOSABLE KDJ

    Patients

    Seq Age Sex Outcome Treatment
    1 65 YR Required Intervention