MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 01,05,07 report with the FDA on 2013-02-19 for INOMAX DSIR (DELIVERY SYSTEM) 10007 manufactured by Ikaria.
[19729163]
Monitored no lower than set no [device issue]. Oxygen requirements increased as measured no values drifted lower [oxygen consumption increased]. Atelectasis [atelectasis]. Increased no to compensate for drifting measured no [therapy regimen changed]. Case description: this initial spontaneous report was received on (b)(6) 2013 from a respiratory therapist (rt) in (b)(6) via the (b)(6). The rt called to discuss why the inomax dsir measured nitric oxide (no) level was reading less than the set no value while in use with a bunnell jet ventilator. Additional info was obtained on (b)(6) 2013. Relevant medical history/comorbidities included: male born at (b)(6) on (b)(6) 2012 weighing (b)(6), ventilator dependent with severe pulmonary interstitial emphysema (pie) and suspected persistent pulmonary hypertension of the newborn (pphn). Inomax therapy was started (date/time not provided) at 20 parts per million (ppm) via the inomax dsir (b)(4). The infant was on the bunnell jet ventilator with an fio2 of 40-50%. Baseline oxygen saturation levels after inomax initiation were in the high 80% to low 90% range. On (b)(6) 2013 an rt noticed that when the no dose was set at 20 ppm, the monitored no reading on the inomax dsir was drifting downward from 20 ppm to 16 ppm to 12 ppm and 8. 5 ppm. In order to keep the pt's oxygen saturation levels at baseline (high 80's to low 90's) the fio2 on the jet vent was increased. By 22:00 the jet vent settings were peak inspiratory pressure (pip) 40, positive end-expiratory pressure (peep) 13, inspiratory time (it) 0. 02, fio2 80-100%, respiratory rate (rr) 360, servo pressure 2. 5 to 2. 9 and conventional ventilator set to continuous positive airway pressure (cpap) 13. The inomax dsir was set at 20 ppm and the monitored no reading was 6 ppm. The rt spoke with both (b)(6) to try to identify the problem. The servo pressure was 2. 9-4, above the recommended low servo pressure limit for the bunnell jet ventilator when in use with the inomax dsir, however the no measured readings still drifted downward. The rt checked all of the connections on the inomax dsir and jet vent, but did not change the jet vent or jet circuitry because it appeared to be working appropriately. The rt wanted to rule out an inomax dsir device problem, so she switched out device (b)(4). The infant was manually ventilated with the inoblender at 20 ppm and 100% oxygen while (b)(4) (involved in the report) was set up. At that point, the pt's oxygen saturation was at baseline (high 80's low 90's). Shortly after being connected to the second inomax dsir (b)(4) with set no of 20 pm, the monitored no started to drift downward. At 23:00 the pt was switched from the jet vent to conventional ventilation drager babylog 8000 assist/control. With the set dose at 20 ppm, the monitored value was 20 ppm, and within 2 hrs the pt's fio2 was reduced back to 40%. On (b)(6) 2013, a chest x-ray showed atelectasis, and the pt was switched back to the jet ventilator (settings of hertz 360 bpm, peep 13, i time. 02, delta p 25, fio2 100%). The inomax dsir (b)(4) was connected and within a few minutes of switching back to the jet, the no readings started to drift down from 20 ppm to 14 ppm. The inomax dsir was checked and reportedly functioned correctly. A decision was made by the neonatologist to treat the pt clinically by titrating the delivery of no to pt response rather than using monitored no since inomax dsir device appeared to be delivering less than set. With tight alarm settings, the set no was at 25 ppm to keep monitored no 19-20 ppm. The pt was also started on steroids. Inomax dsir (b)(4) (see 3004531588-2013-00003) is being returned to ikaria for inspection and once inomax dsir (b)(4) (involved in this report) is removed from the pt, that device will also be returned to (b)(4) for inspection.
Patient Sequence No: 1, Text Type: D, B5
[19837074]
On (b)(6) 2013 a respiratory therapist (rt) in (b)(6) contacted (b)(6) to discuss why inomax dsir device # (b)(4) measured nitric oxide (no) level was reading less than the set no value while in use with a bunnell jet ventilator. ((b)(4)). Company comment dated (b)(6) 2013: the pt required a change in ventilatory strategy in order to reverse the atelectasis seen on non-jet ventilation, as well as significant intervention to avoid a desaturation (increased no dose and increased o2 consumption/fio2 requirements); each of these events is being considered serious.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 3004531588-2013-00004 |
| MDR Report Key | 2971910 |
| Report Source | 01,05,07 |
| Date Received | 2013-02-19 |
| Date of Report | 2013-01-21 |
| Date of Event | 2013-01-12 |
| Date Mfgr Received | 2013-01-21 |
| Date Added to Maude | 2013-02-21 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Reporter Occupation | RESPIRATORY THERAPIST |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | DAVID TRUEBLOOD, DIR |
| Manufacturer Street | 2902 DAIRY DR |
| Manufacturer City | MADISON WI 53718 |
| Manufacturer Country | US |
| Manufacturer Postal | 53718 |
| Manufacturer Phone | 6083953910 |
| Manufacturer G1 | IKARIA |
| Manufacturer Street | 2902 DAIRY DR |
| Manufacturer City | MADISON WI 53718 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 53718 |
| Single Use | 0 |
| Previous Use Code | 0 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | INOMAX DSIR (DELIVERY SYSTEM) |
| Generic Name | APPARATUS, NITRIC OXIDE DELIVERY |
| Product Code | MRQ |
| Date Received | 2013-02-19 |
| Model Number | 10007 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | Y |
| Device Age | DA |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | IKARIA |
| Manufacturer Address | MADISON WI US |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 2013-02-19 |