Polychloroprene Powder-free Surgical Glove (White) Tested for Use with Chemotherapy Drugs; Polychloroprene Powder-free Surgical Glove (Green) Tested for Use with Chemotherapy Drugs

{0}------------------------------------------------ Image /page/0/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized graphic of three human profiles facing right, stacked on top of each other, with flowing lines connecting them. The graphic is encircled by the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" in a circular arrangement. Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002 July 14, 2015 PT Medisafe Technologies Anil Taneja CEO J1. Batang Kuis Gg. Tambak Rejo/ Pasar IX Desa Buntu Bedimbar, Tanjung Morawa Medan, North Sumatra 20362 Indonesia Re: K142190 Trade/Device Trade/Device Name: Polychloroprene Powder-Free Surgical Glove (White) Tested For Use With Chemotherapy Drugs; Polychloroprene Powder-Free Surgical Glove (Green) Tested For Use With Chemotherapy Drugs Regulation Number: 21 CFR 878.4460 Regulation Name: Surgeon's Glove Regulatory Class: I Product Code: KGO, LZC Dated: June 16, 2015 Received: June 19, 2015 Dear Mr. Taneja: We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading. If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register. {1}------------------------------------------------ Page 2 - Anil Taneja Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical devicerelated adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050. If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Industry and Consumer Education at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance. You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Sincerely yours, Tejashri Purohit-Sheth, M.D. Tejashri Purohit-Sheth, M.D. Clinical Deputy Director DAGRID/ODE/CDRH FOR Erin I. Keith, M.S. Division Director Division of Anesthesiology, General Hospital, Respiratory, Infection Control, and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health Enclosure {2}------------------------------------------------ # Indications for Use 510(k) Number (if known) K142190 #### Device Name Polychloroprene Powder-Free Surgical Glove (White) Tested for Use with Chemotherapy Drugs. ### Indications for Use (Describe) A surgeon's glove is a device made of natural or synthetic rubber intended to be worn by operating room personnel to protect a surgical wound from contamination. | Test Chemotherapy Drug | Concentration<br>(mg/ml) | Minimum<br>Breakthrough<br>Detection Time<br>(minutes) | |---------------------------|--------------------------|--------------------------------------------------------| | Carmustine | 3.3 mg/ml | 31.1 | | Cisplatin | 1.0 mg/ml | > 240 min | | Cyclophosphamide | 20.0 mg/ml | > 240 min | | Dacarbazine | 10.0 mg/ml | > 240 min | | Doxorubicin Hydrochloride | 2.0 mg/ml | > 240 min | | Etoposide | 20.0 mg/ml | > 240 min | | Fluorouracil | 50.0 mg/ml | > 240 min | | Ifosfamide | 50.0 mg/ml | > 240 min | | Mechloroethamine HCl | 1.0 mg/ml | > 240 min | | Melphalan | 5.0 mg/ml | > 240 min | | Methotrexate | 25.0 mg/ml | > 240 min | | Paclitaxel | 6.0 mg/ml | > 240 min | | Thiotepa | 10.0 mg/ml | 30.4 | | Vincristine Sulfate | 1.0 mg/ml | > 240 min | Please note that the following drugs have extremely low permeation times: - 1. Carmustine (3.3 mg/ml) : 31.1 minutes. - 2. Thiotepa (10.0 mg/ml) : 30.4 minutes. Type of Use (Select one or both, as applicable) - Prescription Use (Part 21 CFR 801 Subpart D) 2 Over-The-Counter Use (21 CFR 801 Subpart C) # PLEASE DO NOT WRITE BECOW THIS LINE - CONTINUE ON A SEPARATE PAGE IF NEEDED. ### FOR FDA USE ONLY Concurrence of Center for Devices and Radiological Health (CDRH) (Signature) This section applies only to requirements of the Paperwork Reduction Act of 1995, ## *DO NOT SEND YOUR COMPLETED FORM IO THE PRA STAFF EMAIL ADDRESS BELOW.* The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to: > Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staffl PRAStaff@fda.hhs.gov "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number." {3}------------------------------------------------ # Indications for Use 510(k) Number (if known) K142190 #### Device Name Polychloroprene Powder-Free Surgical Glove (Green) Tested for Use with Chemotherapy Drugs. ### Indications for Use (Describe) A surgeon's glove is a device made of natural or synthetic rubber intended to be worn by operating room personnel to protect a surgical wound from contamination. | Test Chemotherapy Drug | Concentration<br>(mg/ml) | Minimum<br>Breakthrough<br>Detection Time<br>(minutes) | |---------------------------|--------------------------|--------------------------------------------------------| | Carmustine | 3.3mg/ml | 0.20 | | Cisplatin | 1.0mg/ml | > 240 min | | Cyclophosphamide | 20.0 mg/ml | > 240 min | | Dacarbazine | 10.0 mg/ml | > 240 min | | Doxorubicin Hydrochloride | 2.0mg/ml | > 240 min | | Etoposide | 20.0 mg/ml | > 240 min | | Fluorouracil | 50.0 mg/ml | > 240 min | | Ifosfamide | 50.0 mg/ml | > 240 min | | Mechlorethamine HCl | 1.0mg/ml | > 240 min | | Melphalan | 5.0mg/ml | > 240 min | | Methotrexate | 25.0 mg/ml | > 240 min | | Paclitaxel | 6.0mg/ml | > 240 min | | Thiotepa | 10.0 mg/ml | 15.4 | | Vincristine Sulfate | 1.0mg/ml | > 240 min | Please note that the following drugs have extremely low permeation times: - 1. Carmustine (3.3 mg/ml) : 0.20 minutes. - 2. Thiotepa (10.0 mg/ml) : 15.4 minutes. Type of Use (Select one or both, as applicable) - Prescription Use (Part 21 CFR 801 Subpart D) 2 Over-The-Counter Use (21 CFR 801 Subpart C) # PLEASE DO NOT WRITE BECOW THIS LINE - CONTINUE ON A SEPARATE PAGE IE NEEDED. ## FOR FDA USE ONLY Concurrence of Center for Devices and Radiological Health (CDRH) (Signature) This section applies only to requirements of the Paperwork Reduction Act of 1995, ## *DO NOT SEND YOUR COMPLETED EORM IO THE PRA STAFF EMAIL ADDRESS BELOW!* The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to: > Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staffl PRAStaff@fda.hhs.gov "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number."