FDA Adverse Event Other Summary report: N

COBE SPECTRA TPE SET

MDR report key: 2498343 · Received March 13, 2012

Report

Report Number
1722028-2012-00147
Event Type
Other
Date Received
March 13, 2012
Date of Event
February 13, 2012
Report Date
February 15, 2012
Manufacturer
CARIDIANBCT
Product Code
FRO
PMA / PMN Number
K020041
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
NC, US
Reporter Occupation
OTHER

Narratives

Additional Manufacturer Narrative · 1

(B)(4). INVESTIGATION: PER THE CUSTOMER, THE PATIENT HAD RUN OUT OF HER MEDICATIONS THE FRIDAY BEFORE THE PROCEDURE, AND HAD NOT HAD THEM REFILLED. SHE WAS NOT ON ANY ACE INHIBITORS. THE PHYSICIANS AND THE PHARMACIST AT THE CUSTOMER SITE BELIEVE THE REACTION WAS RELATED TO THE ALBUMIN THE PATIENT RECEIVED. INVESTIGATION EVALUATION AND CORRECTIVE ACTIONS ARE IN-PROCESS. A FOLLOW-UP REPORT WILL BE PROVIDED.

Additional Manufacturer Narrative · 1

(B)(4). THIS REPORT IS BEING FILED TO PROVIDE ADDITIONAL INFORMATION. THE DEVICE HISTORY RECORD WAS REVIEWED. NOTHING WAS FOUND THAT WAS RELATED TO THIS EVENT. ROOT CAUSE: AFTER EVALUATING ALL THE INFORMATION, THE PATIENT'S PHYSICIAN AND PHARMACIST DETERMINED THAT THE REACTION WAS RELATED TO THE ALBUMIN THE PATIENT RECEIVED. NO ISSUES WITH THE COBE SPECTRA SYSTEM WERE REPORTED BY THE CUSTOMER. ALLERGIC REACTIONS ARE A KNOWN POSSIBLE SIDE EFFECT OF APHERESIS PROCEDURES. ACCORDING TO THERAPEUTIC APHERESIS: A PHYSICIAN'S HANDBOOK, TRANSFUSION REACTIONS MAY OCCUR IN AS MANY AS (B)(4) OF PROCEDURES. THE COBE SPECTRA OPERATOR'S MANUAL WARNS OPERATORS THAT WHEN USING BIOLOGICALLY DERIVED REPLACEMENT FLUIDS, THE PATIENT SHOULD BE CLOSELY MONITORED FOR REACTIONS.

Description of Event or Problem · 1

THE CUSTOMER REPORTED THAT 7 MINUTES INTO A THERAPEUTIC PLASMA EXCHANGE (TPE) PROCEDURE USING A 5% ALBUMIN AS THE REPLACEMENT SOLUTION, A NEW TPE PATIENT BEGAN HAVING HIVES. THE PROCEDURE WAS ENDED AND IV BENADRYL AND SOLUMEDROL WERE GIVEN FOR THE ALLERGIC REACTION. WITHIN AN HOUR THE HIVES RESOLVED. THE CUSTOMER DECLINED TO PROVIDE THE PATIENT IDENTIFIER, DATE OF BIRTH OR WEIGHT. THE DISPOSABLE SET IS UNAVAILABLE FOR RETURN BECAUSE THE CUSTOMER DISCARDED IT. THIS REPORT IS BEING FILED DUE TO MEDICAL INTERVENTION.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 COBE SPECTRA TPE SET SEPARATOR, AUTOMATED, BLOOD CELL, DIAG FRO CARIDIANBCT 01U15202

Patients

Seq Age Sex Outcome Treatment
1 Other ALBUMIN WAS PRE-BOTTLED FROM THE MANUFACTURER CSL| BEHRING IN 250ML BOTTLES.