RecallDepth

Isoflurane E_Vap.(Safety Filling adapter): used with the A9 Anesthesia System-Used to provide the vapor of an anesthetic agent with controllable concentration to an A9 anesthesia system. Part Number: Part Number 115-066758-00

Company
Mindray Ds Usa, Inc. D.B.A. Mindray North America
Recall Initiated
July 22, 2024
Posted
September 4, 2024
Recall Number
Z-2951-2024
Quantity
24 units
Firm Location
Mahwah, NJ

Reason for Recall

V90 electronic vaporizer anesthetic agent output may be higher than the set amount due to a component within the vaporizer causing an incomplete seal in some cases. Should this issue occur, the A9 Anesthesia System will generate alarms associated with abnormal vaporizer output. If the anesthetic concentration is too high, the patient can inhale too much anesthetic agent; the patient may suffer from symptoms such as vertigo and drowsiness after the operation. In severe cases, the patient may suffer from neurological sequelae such as hypomnesia and inattention

Distribution

US Distribution to states of: California, Georgia, Kentucky, Mississippi, New Jersey, Puerto Rico, Texas, and West Virginia; and International (Foreign) to: Canada

Lot / Code Info

UDI-DI: 06936415975753 Serial Number: AH6B24000165 AH6B24000170 AH6B24000167 AH6B24000163 AH6B24000166 AH6B24000173 AH6B24000174 AH6B24000183

Root Cause

Nonconforming Material/Component

Action Taken

Mindray issued an "URGENT Medical Device Recall" letter on July 22, 2024. Letter states reason for recall, health risk and actions to be taken: The V90 electronic vaporizer can continue to be used normally. If "Vaporizer Output Abnormal" alarm or other alarms associated with abnormal vaporizer output or high anesthetic agent alarms occur during use, take appropriate intervention per the A9 Operators manual and contact Mindray Technical Support for assistance. The intervention could be switching to another V90 electronic vaporizer, or the user can decide to switch to intravenous anesthesia. For vaporizer replacement, refer to A9 Operators manual part number H-046-017199-00, section 3.4. Vaporizer . The manual is available on the Mindray website. Mindray s Technical Support team can assist and may be reached at (877) 913-9663 (Option 1) Monday through Friday, 8:30 a.m. 5:30 p.m. ET. Please ensure that applicable clinical staff are aware of the content of this letter. Mindray will replace all affected V90 electronic vaporizers located at your facility. The V90 electronic vaporizers will be shipped directly to your facility, and a Mindray Care Team representative will contact you to schedule the installation and collect the affected V90 electronic vaporizers Contact: Director, Quality Operations and Regulatory Affairs US Agent for Shenzhen Mindray Biomedical Electronics Corp., Ltd Mindray DS USA, Inc. 201.995.8407

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