NUTRILINE
Report
- Report Number
- 2245270-2025-00123
- Event Type
- Malfunction
- Date Received
- October 15, 2025
- Date of Event
- June 9, 2025
- Report Date
- December 15, 2025
- Manufacturer
- VYGON USA
- Product Code
- LJS
- PMA / PMN Number
- K051690
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- CA
- Reporter Occupation
- OTHER HEALTH CARE PROFESSIONAL
- Health Professional
- Yes
Narratives
THE MALFUNCTIONING DEVICE WILL BE RETURNED FOR EVALUATION AS PART OF THE COMPLAINT INVESTIGATION. UPON RECEIPT, IT WILL BE INVESTIGATED. THE RESULTS OF THIS INVESTIGATION ARE STILL PENDING AND WILL BE REPORTED TO THE FDA WITHIN THIRTY DAYS OF ITS CONCLUSION VIA A FOLLOW-UP MDR.
WE RECEIVED THE CATHETER WITH NEEDLE-FREE DEVICE (NON-VYGON GERMANY GMBH) AS FAULTY SAMPLE. DRIED SOLUTION RESIDUES WERE VISIBLE INSIDE EXTENSION LINE AND THE CATHETER TUBE WAS SHORTENED DISTAL TO THE 16 CM MARKING. THE ATTEMPT TO FLUSH THE CATHETER TUBE WITH WATER WAS NOT SUCCESSFUL, PROBABLY DUE TO THE DRIED RESIDUES. MICROSCOPIC EXAMINATION OF THE CATHETER TUBE REVEALED A TEAR DIRECTLY AT THE WING. THE FRACTURE SURFACE WAS ROUGH, INDICATING EXCESSIVE TENSILE FORCE. IN GENERAL, THERE ARE VARIOUS EVENTS THAT CAN LEAD TO A LEAKING CATHETER: 1. TENSILE FORCE: WHICH MAY BE CAUSED BY: - DRESSING CHANGE - IN SOME INSTANCES THE CATHETER CAN BECOME ADHERED TO THE DRESSING AND ADDITIONAL PULLING IS REQUIRED TO FREE IT; PLACING STRESS ON THE LINE COULD RESULT IN A TENSILE FRACTURE. - FOR BABIES, ROUTINE CARE (WHEN LIFTING THE BABY TO CHANGE THE BEDDING) AND MOVEMENT OF THE BABY ITSELF COULD RESULT IN A TENSILE FRACTURE. 2. MECHANICAL DAMAGE BY A SHARP INSTRUMENT (FOR EXAMPLE SCISSOR, FORCEPS OR SCALPEL) DURING DRESSING CHANGE. 3. ALCOHOL-BASED DISINFECTANT - CONCERNING THIS, THERE ARE SOME WARNINGS IN THE IFU: "BE AWARE THAT ORGANIC SOLVENTS SUCH AS ALCOHOL OR ACETONE MAY INTERACT WITH CATHETER MATERIAL AND WEAKEN IT." IN ADDITION, A MANUFACTURING FAULT CAN BE EXCLUDED AS EACH CATHETER IS FLOW AND LEAK TESTED DURING PRODUCTION, AND THE CATHETER DID NOT LEAK FOR 22 DAYS AS STATED BY THE CUSTOMER ("DWELL TIME:22 DAYS"). HAVING CHECKED THE BATCH HISTORY RECORDS; NO DEVIATIONS WERE FOUND. THE BATCH COMPLIED WITH ITS SPECIFICATION AND WAS RELEASED. EACH CATHETER IS FLOW AND LEAK TESTED DURING PRODUCTION. THE TENSILE FORCE AND DIMENSIONS OF CATHETER AND SET COMPONENTS ARE RANDOMLY CHECKED. INCOMING GOODS INSPECTIONS AND TWO 100% VISUAL TESTS AFTER PACKAGING ARE CARRIED OUT. THERE ARE THREE FURTHER COMPLAINTS FOR BATCH 8236275 AND FIVE FURTHER COMPLAINTS REGARDING A LEAKING CATHETER AT THE WING ON PRODUCT CODE 4G07125231 WITHIN THE LAST THREE YEARS. HOWEVER, NONE OF THESE FURTHER COMPLAINTS IS RELATED TO A MANUFACTURING FAULT. THIS QUERY RELATES TO ALL COMPLAINTS THAT HAVE COME TO OUR ATTENTION WORLDWIDE. NO FURTHER CORRECTIVE ACTION WAS INITIATED BY QUALITY MANAGEMENT AS THERE IS NO HINT OF A MANUFACTURING FAULT.
LEAKING, CRACKED NEAR WINGS.
LEAKING, CRACKED NEAR WINGS. PICC REMOVED AND A REPLACEMENT PICC WAS PLACED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 5209 | NUTRILINE | INTRAVASCULAR CATHETR, LONG-TERM | LJS | VYGON USA | 1252.31G | 24F005D |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 2 MO | Male |