MAUDE MDR 3889960

MDR report key
3889960
Report number
1226420-2014-00041
Event key
0
Event type
3
Date of event
2014-05-21
Date received
2014-06-24
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
KAYLEE BOISVERT
Address
180 INTERNATIONAL DRIVE PORTSMOUTH NH 03801 US
Phone
603-603-6038
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1GENERATOR PULSAR REFURBISHEDGENERATOR,ELECTROSURGICAL,COAGULATION,CANCERMEDTRONIC ADVANCED ENERGY, LLCMULPS100-100RFPS100-100RFY R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12014-06-240

Event Narratives#

D

Patient 1

DOCTOR REPORTED THAT HE HAD A SITUATION WHERE THE PLASMABLADE SPARKED WHILE DISSECTING OUT A PATIENT IPG LEADS. AFTER CONNECTING THE NEWLY IMPLANTED LEAD TO THE IPG, IT WAS IMPOSSIBLE TO TURN ON THE PATIENT'S DEVICE OR EVEN CHECK IMPEDANCES WITHOUT HER GETTING PAINFUL SHOCK/JOLT ON THE AFFECTED SIDE OF HER BODY. DEVICE WAS LEFT OFF AND THE PATIENT RETURNED AT A LATER DATE AND THE SAME RESULTS OCCURRED. IT IS UNKNOWN HOW THE SITUATION WILL BE RESOLVED. THE SURGEON ELECTED TO USE THE SYSTEM AGAIN (B)(6) 2014 FOR TWO CASES AFTER SOME DISCUSSIONS AROUND SETTINGS (SURGEON USED A CUT/COAG 5 VERSUS OUR RECOMMENDED CUT/COAG 6) AND EVERYTHING WENT FINE.

D

Patient 1

DOCTOR REPORTED THAT HE HAD A SITUATION WHERE THE PLASMABLADE SPARKED WHILE DISSECTING OUT A PATIENT IPG LEADS. AFTER CONNECTING THE NEWLY IMPLANTED LEAD TO THE IPG, IT WAS IMPOSSIBLE TO TURN ON THE PATIENT?S DEVICE OR EVEN CHECK IMPEDANCES WITHOUT HER GETTING PAINFUL SHOCK/JOLT ON THE AFFECTED SIDE OF HER BODY. DEVICE WAS LEFT OFF AND THE PATIENT RETURNED AT A LATER DATE AND THE SAME RESULTS OCCURRED. IT IS NOT CONFIRMED HOW THE SITUATION WILL BE/WAS RESOLVED. THE SURGEON ELECTED TO USE THE SYSTEM AGAIN (B)(6) 2014 FOR TWO CASES. AFTER SOME DISCUSSIONS AROUND SETTINGS (SURGEON USED A CUT/COAG 5 VERSUS OUR RECOMMENDED CUT/COAG 6) AND EVERYTHING WENT FINE.

N

Patient 1

(B)(4). METHOD: FACILITY NOT RETURNING PRODUCT AS IT WAS USED SUBSEQUENTLY WITH NO FURTHER ISSUES. EVAL CODE RESULTS: FACILITY NOT RETURNING PRODUCT AS IT WAS USED SUBSEQUENTLY WITH NO FURTHER ISSUES. CONCLUSION: FACILITY NOT RETURNING PRODUCT AS IT WAS USED SUBSEQUENTLY WITH NO FURTHER ISSUES. PRODUCT EVENT: (B)(4).

N

Patient 1

PRODUCT EVENT #(B)(4) EVALUATION PROCESS: UNIT RECEIVED IN STANDARD SHIPPING CONTAINER. UNIT RECEIVED IN FAIR CONDITION WITH MINOR SURFACE IMPERFECTIONS INCLUDING STAINING TO LOWER CASE. POWER CORD AND USER MANUAL WERE RECEIVED WITH UNIT. NO HAND PIECES WERE RECEIVED. INTERNAL VISUAL INSPECTION FUND NOTHING MOVING OR BROKEN IN UNIT. UNIT DELIVERED RF ENERGY CORRECTLY INTO FIXED RESISTORS. QUALITATIVE OBSERVATION, WHILE DELIVERING ENERGY TO A SALINE BATH, SHOWED KNOWN AMOUNTS OF ARCING. UNIT GENERATED A SMALL ARC WHEN TOUCHED TO METAL PLATE UNDER ANALOG SUBSTANCE. THIS EXPERIMENT WAS REPEATED, WITH SIMILAR RESULTS, WITH PULSAR GENERATOR NUMBER 09P00479. THE ERROR LOG REVEALED THAT THE UNIT WAS POWERED UP ON AT LEAST 1 UNIQUE DAY WHILE IN THE FIELD (THE ERROR LOG INDICATES THAT THE UCB BATTERY DIED AFTER UNIT SHIPPED TO THE CUSTOMER ON(B)(6) 2013 BUT BEFORE FIRST USE IN THE FIELD.) ERROR LOG CONTAINS 2 E3S (PATIENT RETURN ELECTRODE HAS POOR CONNECTION) AND 2 E11S (PATIENT RETURN ELECTRODE DISCONNECTED.) ALL ERROR LOG ENTRIES ARE CONSIDERED ?NORMAL USE? ERRORS AND ARE NOT INDICATIVE OF A PROBLEM WITH THE UNIT. ROOT CAUSE: IF THE POWER LEVEL ON THE PULSAR GENERATOR IS HIGH ENOUGH, THE PLASMABLADE WILL EMIT AN ARC WHEN NEAR A METAL PLATE IN A SALINE BATH (ACTING AS A PATIENT ANALOG.) NO PERFORMANCE ISSUES NOTED WITH THE GENERATOR. (B)(4).

N

Patient 1