FDA Adverse Event Other Summary report: N

FRESENIUS 2008H

MDR report key: 977202 · Received August 8, 2007

Report

Report Number
977202
Event Type
Other
Date Received
August 8, 2007
Date of Event
July 11, 2007
Report Date
July 24, 2007
Manufacturer
FRESENIUS USA
Product Code
FII
Product Problem
Yes
Report Source
User Facility report
Reporter Location
LA, US
Reporter Occupation
RISK MANAGER

Narratives

Description of Event or Problem · 1

PT IS ONE OF TWO PTS W/LOW SODIUM BALANCE AND VOLUME OVERLOAD AFTER DIALYSIS TX ON SPECIFIC DIALYZER. PT SEIZED IN DIALYSIS, REVIVED. PT W/PRIOR HX OF SEIZURES, CT NEGATIVE. PT FOLLOWED IN ICU, CONTINUED DIALYSIS, RETURNED TO BASELINE. TESTING OF MACHINE POST-EVENT REVEALS CONDUCTIVITY CALIBRATION ANOMALY (INTERNAL READOUT: 13.3, EXTERNAL METER: 9.6) AND ACID PUMP PUMPING AT LOW VOLUME (91, S/B 150-157). PUMP DID NOT ALARM DURING TESTING PROCEDURE. PUMP SEALS/SPRING CORRODED, PUMP REPLACED. PUMP SENT TO MG FOR FAILURE ANALYSIS REPORT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 FRESENIUS 2008H HEMODIALYSIS SYSTEM FII FRESENIUS USA 2008H *

Patients

Seq Age Sex Outcome Treatment
1 45 YR Other