FDA Adverse Event Injury Summary report: N

ISCUS FLEX MICRODIALYSIS ANALYZER

MDR report key: 7784286 · Received August 14, 2018

Report

Report Number
MW5079142
Event Type
Injury
Date Received
August 14, 2018
Date of Event
June 27, 2018
Report Date
August 10, 2018
Manufacturer
M DIALYSIS INC., AB
Product Code
PPM
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
NY, US
Reporter Occupation
PHYSICIAN

Narratives

Description of Event or Problem · 1

BOTH OF OUR CEREBRAL MICRODIALYSIS, (CMD) ANALYZERS WERE RENDERED INOPERABLE, NO RESULTS COULD BE OBTAINED FOR THIS PT ON (B)(6) 2018. FROM 2015 TO 2017, ONE OR BOTH OF OUR CMD ANALYZERS WERE DOWN 22% OF THE TIME, WITH PROLONGED DOWNTIME INTERVALS. THIS ANALYZER PLATFORM IS UNFIT FOR CLINICAL USE. DATES OF USE: 2014, (B)(6) 2018. DIAGNOSIS OR REASON FOR USE: CEREBRAL TRAUMA MONITORING. THE ORDERING CLINICIANS WERE NOTIFIED THAT THESE RESULTS WOULD NOT BE AVAILABLE. LAB LEADERSHIP HAS NOTIFIED THE VENDOR AS OF (B)(6) 2018 OF THE INTENT TO DISCONTINUE THIS TESTING DUE TO PERSISTENT, AND ONGOING ANALYZER PLATFORM INSTABILITY. AN UNSTABLE PLATFORM SUCH AS THE CMD ANALYZER, WHEN COUPLED WITH THE INAPPROPRIATELY PROLONGED INTERVALS TO SCHEDULING FIELD SERVICE ENGINEER ARRIVALS FOR REPAIRS (OFTEN GREATER THAN ONE WEEK) RENDERS THE CMD ANALYZER DEVICE COMPLETELY UNSAFE FOR ITS INTENDED CLINICAL USE IN CEREBRAL MONITORING FOR PTS AT RISK WITH ACUTE TRAUMATIC BRAIN INJURIES. FIELD SVC ENGINEER FOR THE CMD ANALYZERS COULD NOT BE SCHEDULED IN A REASONABLE TIME FRAME TO ENABLE SAFE CLINICAL APPLICATION OF THIS PRODUCT TO OUR PTS. THESE IMPLANTED BRAIN CATHETERS ARE CONNECTED TO A PUMP, AND THE FLUIDS REMOVED FROM PTS' BRAINS ARE SENT TO THE LAB IN SPECIAL MICROVIALS FOR ANALYSIS ON THE CMD ANALYZER.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
621025 ISCUS FLEX MICRODIALYSIS ANALYZER GENERAL PURPOSE REAGENT PPM M DIALYSIS INC., AB 641564
621026 ISCUS FLEX MICRODIALYSIS ANALYZER GENERAL PURPOSE REAGENT PPM M DIALYSIS INC., AB 614565

Patients

Seq Age Sex Outcome Treatment
1 21 YR Hospitalization