EBME Forums Forums Maintenance Technical Assistance BBraun Perfusor Invalid Syringe 50ml BD Plastipak

I had a quick search and tried goggle and found nothing, so accept my apologies if this issue has already been covered....

In addition to the occlusion issues we are currently seeing with recent batches of BD plastipak 50ml syringes, a new problem has reared it's head.

One of our perfusors failed to recognise a BD plastipak 50ml syringe the other day reporting - no biggie I think, quick re-cal and all will be fine.

No joy. Another re-cal and a config upload and the condition remains.

Defeated, I push the unit to one side to look at again, when time allows.

This morning, another pump with the same issue. I found an old BD plastipak 50ml syringe, both pumps recognised this syringe immediately.
A pair of vernier callipers showed that the new troublesome syringe was a fraction smaller than the old acceptable one.
As a test, a couple of turns of tape around the syringe body to build up the diameter and it was recognised by the BBraun pump.

As the problem is not affecting all of our BBraun Perfusors , it would seem that the new diameter body is sitting at the bottom of the tolerance band for recognising BD plastipak 50ml syringes and then any tolerance issues with the syringe size potentiometer means that the problems are somewhat sporadic.

Has anyone else out there encountered this problem?

Doubtless you are aware that BD redesigned their 50ml offering and this has resulted in quite serious issues with syringe pumps alarming occlusion. BD published a long explanation with the bottom line basically saying go & set up each & every device it's used with for new occlusion pressure threshold alarms. No further comment.

We had these issues a couple of years ago when syringe design was changed, I remember posting here but no one else appeared to have problems at the time. I complained to BD and reported to MHRA. An alert was issued last year - see MDA/2013/024

Issue resolved with assistance from Technical Services at B Braun.

We had been incorrectly loading the test pieces during the syringe size sensor recalibration process, loading it entirely under the syringe clamp assembly and the syringe plunger brake housing.

The correct method is to load the test piece so that it is not under the plunger brake housing and flush with the outer edge of the green syringe collar clamp.

The slight discrepancy in calibrated diameter coupled with the small reduction in barrel diameter on the BD syringes was just enough to render the syringe 'invalid'

A check of all our pumps, has only found two pumps affected, both have been recalibrated correctly and returned to service.

BD have issued an update re the problem.
No need to alter pumps, if you have done you may have to go back and unalter.

KM, you beat me to it.
Alert MDA/2014/003 has just been issued.

Just seen the MHRA Alert. Does this mean that there are continued problems until we get the new stock?

Also, any advice on how best to manage the change of BD stock when the new one arrives. I guess this will have to be done ward by ward, changing the pressure alarms and stock one ward at a time.

BD have released a field service notice about their 50ml syringes
Robert

I'm interested to see just how widespread the issues with BD 50ml syringes has been. In my organisation we have a significant number of incidents involving these, at a rate of 1 per week and some were very near misses. We have had on-going issues for a year. As a result we have taken the decision to switch, next week, to an alternative manufacturer. As this involves c.3500 syringe pumps across 11 acute sites, not a decision taken lightly.

As one who monitors clinical incidents I can confirm there have been regular reports of occlusion problems with the new style BD syringe and I'm sure there have been others that have gone unreported. It is a serious problem & BD's initial proposed solution was unacceptable but as you point out a change of supplier is also a daunting prospect.
Abstracting from this specific problem I would like to see decision makers take into account scenarios like this when choosing either single use devices or equipment that depend on dedicated single use sets - the supply chain needs to be secured. We've also had disrupted services due to factories that produce these consumables wiped out in Tsunamis, Typhoons, Hurricanes & earthquakes - I could end by pleading to bring jobs back from disaster prone countries but does anyone know of a dry spot in the UK right now?