MAUDE MDR 2194686

MDR report key
2194686
Report number
1226348-2011-00268
Event key
0
Event type
3
Date of event
2011-05-27
Date received
2011-07-13
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
MATTHEW KING
Address
325 PARAMOUNT DR. RAYNHAM MA 02767 US
Phone
508-508-5088
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1HAKIM VENTRICULAR & PERITONEAL CATHETERS WITH BACTISEALSHUNT, CENTRAL NERVOUS SYSTEM & COMPSCODMAN & SHURTLEFF, INC. MEDOS S.A.HCANA82-3072CJCBK6Y Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12011-07-1301. R

Event Narratives#

D

Patient 1

MEDWATCH EXPLAINS THAT PT IS A TODDLER. SHUNT WAS PLACED APPROX 2.5 YRS AGO FOR HYDROCEPHALUS. PT WAS NOTED TO HAVE POOLING OF SUBCUTANEOUS FLUID AROUND THE SHUNT COMPONENTS. A SHUNT SURVEY WAS DONE AND SHOWED A DISCONNECTION JUST AT THE BOTTOM SIDE OF HER VALVE. CSF WAS FOUND TO BE FREELY COMING FROM THE DISTAL VALVE. THE ORIGINAL CONNECTION OF THE DISTAL CATHETER TO THE VALVE WAS STILL INTACT WITH THE SUTURE IN PLACE, BUT THE CATHETER HAD RUPTURED JUST 0.5 CM BELOW THIS. A NEW BACTISEAL PERITONEAL TUBING WAS PULLED INTO PLACE. THE OLD PERITONEAL CATHETER WAS THEN REMOVED AND WAS SENT FOR PATHOLOGIC EVAL.

N

Patient 1

UPON COMPLETION OF THE INVESTIGATION, A FOLLOW UP REPORT WILL BE FILED.

N

Patient 1

DEVICE EVALUATION: IT WAS DISCOVERED THAT THIS COMPLAINT HAS BEEN REPORTED TWICE. AS A RESULT (B)(4) IS BEING CLOSED. PLEASE ALSO REFER TO COMPLAINT (B)(4) FOR THE COMPLAINT EVALUATION. UPON COMPLETION OF THE INVESTIGATION IT WAS NOTED THAT ONE END OF THE CATHETER HAD A CLEAN CUT AND THE OTHER END WAS SLIGHTLY JAGGED. IT WAS ALSO NOTED THAT DURING IRRIGATION OF THE DEVICE AN OCCLUSION WAS FOUND ALONG WITH CLEAR BIOLOGICAL PARTICLES THAT WAS FLUSHED FROM THE CATHETER. IT APPEARS THE PROBLEM REPORTED BY THE CUSTOMER WAS CAUSED FROM THE OCCLUSION THAT WAS NOTED. IT IS NOT CLEAR HOW THE RUPTURE OF THE CATHETER HAPPENED. IT IS INDICATED IN THE INSTRUCTIONS FOR USE THAT EXTREME CARE SHOULD BE USED WHEN HANDLING SILICONE PRODUCTS AS SILICONE HAS A LOW TEAR RESISTANCE. A REVIEW OF THE DEVICE HISTORY RECORDS CONFIRMED THAT THE DEVICE CONFORMED TO THE REQUIRED SPECIFICATIONS WHEN RELEASED TO STOCK. BASED ON THE RESULTS OF THIS INVESTIGATION, NO FURTHER ACTION IS REQUIRED. TRENDS WILL BE MONITORED FOR THIS AND SIMILAR COMPLAINTS. AT THE PRESENT TIME THIS COMPLAINT IS CLOSED.

N

Patient 1

A FOLLOW UP REPORT IS BEING FILED IN AN ATTEMPT TO CLARIFY THE INVESTIGATION RESULTS. UPON COMPLETION OF THE INVESTIGATION IT WAS NOTED THAT ONE END OF THE CATHETER HAD A CLEAN CUT AND THE OTHER END WAS SLIGHTLY JAGGED. IT WAS ALSO NOTED THAT DURING IRRIGATION OF THE DEVICE AN OCCLUSION WAS FOUND ALONG WITH CLEAR BIOLOGICAL PARTICLES THAT WAS FLUSHED FROM THE CATHETER. THE ROOT CAUSE OF THE SUBCUTANEOUS ACCUMULATION OF FLUID REPORTED BY THE CUSTOMER APPEARS TO HAVE BEEN CAUSED BY THAT OF A RUPTURE IN THE CATHETER. THE ROOT CAUSE OF THE RUPTURE OF THE CATHETER WAS NOT CLEARLY DETERMINED HOWEVER AS NOTED IN THE IFU, SILICONE HAS A LOW CUT AND TEARS RESISTANCE AND MUST BE HANDLED WITH CARE. A REVIEW OF THE DEVICE HISTORY RECORDS CONFIRMED THAT THE DEVICE CONFORMED TO THE REQUIRED SPECIFICATIONS WHEN RELEASED TO STOCK. BASED ON THE RESULTS OF THIS INVESTIGATION, NO FURTHER ACTION IS REQUIRED. TRENDS WILL BE MONITORED FOR THIS AND SIMILAR COMPLAINTS. AT THE PRESENT TIME THIS COMPLAINT IS CLOSED.