FDA Adverse Event Injury Summary report: N

SYNCHROMED II

MDR report key: 2771540 · Received October 4, 2012

Report

Report Number
3004209178-2012-08864
Event Type
Injury
Date Received
October 4, 2012
Report Date
September 12, 2012
Manufacturer
MDT PUERTO RICO OPERATIONS CO
Product Code
LKK
PMA / PMN Number
P860004
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
MA, US
Reporter Occupation
PHYSICIAN

Narratives

Additional Manufacturer Narrative · 1

(B)(4).

Additional Manufacturer Narrative · 1

PRODUCT ID 8709SC, SERIAL# (B)(4), IMPLANTED: (B)(6) 2011, PRODUCT TYPE CATHETER. (B)(4).

Additional Manufacturer Narrative · 1

PRODUCT ID 8709SC, SERIAL# (B)(4), IMPLANTED: (B)(6) 2011, EXPLANTED: (B)(6) 2013, PRODUCT TYPE CATHETER. PUMP AND CATHETER ANALYSIS RESULTS WERE NOT AVAILABLE AS OF THE DATE OF THIS REPORT. A FOLLOW-UP REPORT WILL BE SUBMITTED WHEN ANALYSIS IS COMPLETE.

Additional Manufacturer Narrative · 1

(B)(4).

Additional Manufacturer Narrative · 1

IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

Additional Manufacturer Narrative · 1

(B)(4).

Description of Event or Problem · 1

IT WAS REPORTED THERE WAS A MOTOR STALL WITHOUT RECOVERY. THE PATIENT FELL ON (B)(6) 2012 AND THE ALARM ON HIS PUMP BEGAN TO SOUND SOMETIME AFTER THE FALL. THE PATIENT STATED THAT DUE TO THE FALL IT WAS FELT THAT HE 'BROKE THE PUMP.' THE PATIENT WAS SEEN BY THE HEALTHCARE PROVIDER (HCP) ON (B)(6) 2012 AND A MOTOR STALL OCCURRENCE WAS DISCOVERED. THE HCP WAS UNABLE TO REMOVE MOTOR STALL AFTER REPEATED INTERROGATION OF THE PUMP. PER THE PUMP LOGS, THE MOTOR STALL OCCURRED ON (B)(6) 2012 AT 0330 AND STILL HAD NOT RECOVERED BY (B)(6) 2012 0330, AS THE LOGS DISPLAYED 'STOPPED PUMP PERIOD MAY EXCEED TUBE SET' AT THAT TIME. THE PATIENT EXPERIENCED SYMPTOMS WHICH WERE DESCRIBED AS 'FEELING FLUID IN HIS ABDOMEN' AND 'FULLNESS.' PATIENT FURTHER DESCRIBED A FEELING 'LIKE IT WAS TRICKLING DOWN TO HIS LEGS,' AND A RETURN OF RESTLESS LEGS. THE PATIENT DECLINED ANY INTERVENTION AT THAT TIME AS IT WAS FELT THERE WAS NO ADEQUATE RELIEF SINCE BEING IMPLANTED. IT WAS LATER REPORTED THAT ACCORDING TO TELEMETRY THE PUMP WAS FULL. AS OF (B)(6) 2012, THE PUMP STILL HAD NOT RECOVERED FROM THE MOTOR STALL AND IT WAS UNKNOWN WHAT THE EXACT CAUSE OF THE STALL WAS. THE MEDICATIONS IN THE PUMP WERE HYDROMORPHONE, BUPIVACAINE AND BACLOFEN. PATIENT AND EVENT OUTCOME WERE NOT PROVIDED. ADDITIONAL INFORMATION HAS BEEN REQUESTED, BUT WAS NOT AVAILABLE AS OF THE DATE OF THIS REPORT.

Description of Event or Problem · 1

ADDITIONAL INFORMATION: THE PATIENT HAD A KUB (KIDNEY, URETER, BLADDER), NOT KUV, X-RAY TO DETERMINE PUMP POSITION INSTEAD OF AN MRI.

Description of Event or Problem · 1

ADDITIONAL INFORMATION INDICATED THAT THE PATIENT'S PUMP WAS EXPLANTED ALONG WITH PART OF THE CATHETER. NO ADDITIONAL INFORMATION WAS AVAILABLE AT THE TIME OF THIS SUBMISSION. A FOLLOW-UP REPORT WILL BE SUBMITTED IF FURTHER INFORMATION IS RECEIVED.

Description of Event or Problem · 1

ADDITIONAL INFORMATION RECEIVED REPORTED THAT THE PATIENT WAS HAVING AN MRI ON (B)(6) 2012, WHICH HAD TO BE STOPPED BECAUSE THE PATIENT "FAILED" IT DUE TO NEEDING A "KUV" AND NOT BEING ABLE TO BE STILL LONG ENOUGH FOR THE SCAN, AS THE PATIENT WAS IN "SO MUCH PAIN". THE DETAILS OF THE PATIENT ISSUES AT THE TIME OF THE MRI WERE UNKNOWN TO THE REPORTER. IT WAS LATER REPORTED THAT THE PATIENT'S MOTOR STALL WHICH WAS ALREADY REPORTED, REMAINED STALLED PERMANENTLY. NO OTHER INFORMATION WAS PROVIDED. ADDITIONAL INFORMATION HAS BEEN REQUESTED, BUT WAS NOT AVAILABLE AS OF THE DATE OF THIS REPORT

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 SYNCHROMED II PUMP, INFUSION, IMPLANTED, PROGRAMMABLE LKK MDT PUERTO RICO OPERATIONS CO 8637-40

Patients

Seq Age Sex Outcome Treatment
1 00062 YR Required Intervention