K Number
K221411
Date Cleared
2023-06-23

(403 days)

Product Code
Regulation Number
880.5440
Reference & Predicate Devices
Predicate For
N/A
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP AuthorizedThirdpartyExpeditedreview
Intended Use

The Surflo Winged Infusion Set is indicated for venipuncture and intravenous administration of fluids for up to 24 hours using compatible/appropriate disposable infusion devices for medical purposes. It may be used for any patient population with consideration given to patient size.

Device Description

The Surflo Winged Infusion Set consists of a protector, needle, wing, tubing, connector, and connector cap. The connector is 6% female Luer. It is primarily made from medical grade PVC (the whole device uses TOTM as plasticizer instead of DEHP) and medical grade stainless steel. The Surflo Winged Infusion Set is operated manually. The device is intended to be used by trained healthcare professionals in a healthcare facility. The Surflo Winged Infusion Set is available in different gauge sizes and tubing lengths. The Surflo Winged Infusion Set is a disposable device intended for single use only. The device is packaged and sterilized by ethylene oxide gas.

AI/ML Overview

This document is a 510(k) Premarket Notification for the Surflo Winged Infusion Set, seeking substantial equivalence to a legally marketed predicate device. As such, it describes performance testing conducted to demonstrate product safety and effectiveness, rather than a study proving a device meets acceptance criteria for an AI/ML product. Therefore, several points in your requested output, such as those related to AI/ML specific criteria (e.g., sample size for training set, number of experts for ground truth establishment, MRMC study, standalone performance) are not applicable to this type of medical device submission.

However, I can extract and present the relevant information regarding acceptance criteria and performance testing for this traditional medical device:

Acceptance Criteria and Device Performance for Surflo Winged Infusion Set

The Surflo Winged Infusion Set underwent non-clinical performance testing to ensure it met predetermined specifications, conformed to applicable ISO and non-ISO standards, and demonstrated substantial equivalence to its predicate device.

1. Table of Acceptance Criteria (Standard Compliance) and Reported Device Performance

For tests conducted against specific standards, the document implies that compliance with the standard is the acceptance criterion. For additional performance tests, the acceptance criterion was "Meets acceptance criteria," established based on the predicate device's performance.

TestStandard / Acceptance CriteriaReported Device Performance
Flow rateGB 18671-2009 Intravenous needles for single useComplies with standard
Leak testJIS T 3222:2011 Sterile winged intravenous devicesComplies with standard
Wing to tubing connection strength (static pull force)ISO 8536-4:2019 Infusion equipment for medical useComplies with standard
Tubing to connector connection strength (static pull force)ISO 8536-4:2019 Infusion equipment for medical useComplies with standard
Needle to wing connection strength (static pull force)ISO 8536-4:2019 Infusion equipment for medical useComplies with standard
Needle curvatureJIS T 3222:2011 Sterile winged intravenous devicesComplies with standard
Wing to tubing connection strength (dynamic pull force)Meets acceptance criteria (based on predicate)Meets acceptance criteria
Tubing to connector connection strength (dynamic pull force)Meets acceptance criteria (based on predicate)Meets acceptance criteria
Needle to wing connection strength (dynamic pull force)Meets acceptance criteria (based on predicate)Meets acceptance criteria
Wing-needle protector fitMeets acceptance criteria (based on predicate)Meets acceptance criteria
Needle penetration resistanceMeets acceptance criteria (based on predicate)Meets acceptance criteria
Blockage testMeets acceptance criteria (based on predicate)Meets acceptance criteria
Priming volumeMeets acceptance criteria (based on predicate)Meets acceptance criteria

2. Sample Size Used for the Test Set and Data Provenance

The document does not explicitly state the sample sizes used for each performance test. It only mentions that "Performance testing was conducted to ensure the Surflo Winged Infusion Set met the predetermined specifications." The data provenance is implied to be from the manufacturer's internal testing facilities in Hangzhou, China, as it is manufactured by "Terumo Medical Products (Hangzhou) Co., Ltd." The testing is described as non-clinical, implying a prospective testing approach conducted specifically for this 510(k) submission.

3. Number of Experts Used and Qualifications

Not applicable. This is a non-clinical performance test for a traditional medical device, not a study requiring expert readers for ground truth establishment.

4. Adjudication Method for the Test Set

Not applicable. This is a non-clinical performance test for a traditional medical device, not a study requiring adjudication of expert readings.

5. Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study

Not applicable. This is a non-clinical performance test for a traditional medical device, not a study evaluating human reader performance with or without AI assistance.

6. Standalone Performance (Algorithm Only)

Not applicable. This is a traditional medical device, not an AI/ML algorithm.

7. Type of Ground Truth Used

The "ground truth" for the performance tests were adherence to established industry standards (ISO, JIS, GB) and internal company specifications derived from the predicate device's performance.

8. Sample Size for the Training Set

Not applicable. This is a traditional medical device, not an AI/ML product requiring a training set.

9. How the Ground Truth for the Training Set was Established

Not applicable. This is a traditional medical device, not an AI/ML product requiring a training set.

Additional Test Information:

  • Biocompatibility: Tests were conducted on non-aged and accelerated-aged devices according to ISO 10993-1, with results demonstrating biocompatibility throughout the product's shelf life.
  • Sterilization: The device is sterilized to a Sterility Assurance Level (SAL) of 10^-6, validated in accordance with ISO 11135:2014.
  • Clinical Tests: The 510(k) submission states that it "does not include data from clinical tests."

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Image /page/0/Picture/0 description: The image shows the logo of the U.S. Food and Drug Administration (FDA). The logo consists of two parts: on the left, there is a symbol representing the Department of Health & Human Services - USA, and on the right, there is the text "FDA U.S. FOOD & DRUG ADMINISTRATION" in blue. The word "FDA" is in a larger, bolder font and is placed above the rest of the text. The text is aligned to the right of the symbol.

June 23, 2023

Terumo Medical Products (Hangzhou) Co., Ltd. % Brian Byrd Regulatory Affairs Specialist Terumo Medical Corporation 265 Davidson Avenue, Suite 320 Somerset, New Jersey 08873

Re: K221411

Trade/Device Name: Surflo Winged Infusion Set Regulation Number: 21 CFR 880.5440 Regulation Name: Intravascular administration set Regulatory Class: Class II Product Code: FPA Dated: June 19, 2023 Received: June 20, 2023

Dear Brian Byrd:

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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. 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.

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

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requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (OS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

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 https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about mediation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE(@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

David Walloschek

David Wolloscheck, Ph.D. Assistant Director DHT3C: Division of Drug Delivery and General Hospital Devices. and Human Factors OHT3: Office of GastroRenal, ObGyn, General Hospital and Urology Devices Office of Product Evaluation and Ouality Center for Devices and Radiological Health

Enclosure

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Indications for Use

510(k) Number (if known) K221411

Device Name Surflo Winged Infusion Set

Indications for Use (Describe)

The Surflo Winged Infusion Set is indicated for venipuncture and intravenous administration of fluids for up to 24 hours using compatible/appropriate disposable infusion devices for medical purposes. It may be used for any patient population with consideration given to patient size.

Type of Use (Select one or both, as applicable)

Research Use Only (21 CFR 801.4; Subpart B)
For In-Vitro Use Only (21 CFR 801.4; Subpart I)

Prescription Use (Part 21 CFR 801 Subpart D)

__ Over-The-Counter Use (21 CFR 801 Subpart C)

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Image /page/3/Picture/1 description: The image shows the Terumo company logo. The logo consists of a red arc above the word "TERUMO" in green. The arc is positioned above and to the left of the word, creating a sense of motion or direction.

K221411 510(K) SUMMARY

A. SUBMITTER INFORMATION (807.92(a)(1))

Prepared by: Brian Byrd Regulatory Affairs Specialist Terumo Medical Corporation Tel. (908) 208-5226 Fax (410) 398-6079

Prepared for: Owner/Operator

Terumo Medical Products (Hangzhou) Co., Ltd. M4-9-5, Hangzhou Economic & Technological Development Zone Hangzhou, Zhejiang CN 310018 Owner/Operator Number: 10033965

Manufacturer and Sterilization Facility (Applicant)

Terumo Medical Products (Hangzhou) Co., Ltd. M4-9-5, Hangzhou Economic & Technological Development Zone Hangzhou, Zhejiang CN 310018 Registration Number: 3004102031

Contact Person: Brian Byrd

Regulatory Affairs Specialist Terumo Medical Corporation 265 Davidson Avenue, Suite 320 Somerset, NJ 08873 Tel. (908) 208-5226 Fax (410) 398-6079 E-mail: brian.byrd@terumomedical.com

June 20, 2023 Date prepared:

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B. DEVICE NAME (807.92(a)(2))

Proprietary Name:Surflo Winged Infusion Set
Common Name:Intravascular Administration Set
Classification Name:Intravascular Administration Set
Classification Panel:General Hospital
Regulation:21 CFR 880.5440
Product Code:FPA
Classification:Class II

C. PREDICATE DEVICE (807.92(a)(3))

The legally marketed device to which substantial equivalence is claimed is:

Primarv Predicate:

  • . K 771204 - Surflo Winged Infusion Set, manufactured by Kofu Factory of Terumo Corporation.

D. REASON FOR 510(k) SUBMISSION

This Traditional 510(k) is being submitted for the Surflo Winged Infusion Set, an intravascular administration set manufactured by Terumo Medical Products (Hangzhou) Co., Ltd., for the purposes of establishing substantial equivalence to a legally marketed predicate device. The device design remains the same excluding the material of the Connector Cap, available needle lengths, and solvent for the tubing/connector. The remaining components including the needle are the same.

E. INDICATIONS FOR USE (807.92(a)(5))

The Surflo Winged Infusion Set is indicated for venipuncture and intravenous administration of fluids for up to 24 hours using compatible/appropriate disposable infusion devices for medical purposes. It may be used for any patient population with consideration given to patient size.

F. DEVICE DESCRIPTION (807.92(a)(4))

The Surflo Winged Infusion Set consists of a protector, needle, wing, tubing, connector, and connector cap. The connector is 6% female Luer. It is primarily made from medical grade PVC

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Image /page/5/Picture/1 description: The image shows the Terumo company logo. The logo consists of a red arc above the company name, which is written in green, block letters. The arc is positioned above and to the left of the word "TERUMO."

(the whole device uses TOTM as plasticizer instead of DEHP) and medical grade stainless steel.

The Surflo Winged Infusion Set is operated manually. The device is intended to be used by trained healthcare professionals in a healthcare facility.

The Surflo Winged Infusion Set is available in different gauge sizes and tubing lengths. Table 5.1 shows the available product codes and their specifications.

ProductcodeNeedlegauge(mm)*Wallthickness**Needlelength(inch)Tubinglength(mm)TubingInner / OuterDiameter(mm)Primingvolume(ml)Wingtype***
SV*18BLK18G (1.20)TW3/43001.2/2.20.45±0.10C
SV*19BLK19G (1.10)TW3/43001.2/2.20.45±0.10C
SV*21BLK21G (0.80)UTW3/43001.1/2.10.41±0.08C
SV*22BLK22G (0.70)UTW3/43001.1/2.10.41±0.08C
SV*23BLK23G (0.65)UTW3/43001.1/2.10.40±0.08C
SV*25BLK25G (0.50)TW3/43001.1/2.10.40±0.08C
SV*19BLS19G (1.10)TW3/4901.2/2.20.21±0.08C
SV*21BLS21G (0.80)UTW3/4901.1/2.10.20±0.08C
SV*23BLS23G (0.65)UTW3/4901.1/2.10.20±0.08C
SV*25BLS25G (0.50)TW3/4901.1/2.10.19±0.08C
SV*25EL25G (0.50)TW1/22001.1/2.10.30±0.05D
SV*27EL27G (0.40)RW1/22001.1/2.10.30±0.05D

Table 5.1 Surflo Winged Infusion Set specifications

*Referred to as Needle I/OD in Performance Testing

**TW = Thin Wall, UTW = Ultra-Thin Wall, RW = Regular Wall

***Wing Type: See Figure 11.1 in Section 11 - Device Description for differences in dimensions

The Surflo Winged Infusion Set is a disposable device intended for single use only. The device is packaged and sterilized by ethylene oxide gas.

Mechanical Specifications applicable to the Surflo Winged Infusion Set:

Tensile stress strength when100% elongatedTensile fracture strength
PVC (TR-630T) [tubing]5.84±1.96 MPa17.3±4.9 MPa

Table 5.2 Strength of material (body-contacting material)

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PVC (R-500T) 【wing】$10.3\pm2.9$ MPa$22.2\pm5.9$ MPa
Izod impact strength
PMMA 【connector】>68.6J/m

Tubing elongation: 410~490%

G. SUBSTANTIAL EQUIVALENCE COMPARISON (807.92(a)(6))

The Surflo Winged Infusion Set, subject of this 510(k), is substantially equivalent in its intended use/indications for use, technology/principal of operation, materials, and performance to the Surflo Winged Infusion Set (K771204), manufactured by Kofu Factory of Terumo Corporation, Japan.

A comparison of the technological characteristics is summarized in the table below:

DeviceCharacteristicSubject Device: SurfloWinged Infusion SetPredicate: SurfloWinged Infusion Set,K771204
ManufacturerTerumo Medical Products(Hangzhou) Co., Ltd.Terumo Corporation
Intended UseThe Surflo WingedInfusion Set is a deviceused to administer fluidsfrom a container to apatient's vascular systemthrough a needleinserted in a vein.Same
Indications forUseThe Surflo Winged InfusionSet is indicated forvenipuncture andintravenous administration offluids for up to 24 hoursusing compatible/appropriatedisposable infusion devicesfor medical purposes. It maybe used for any patientpopulation withconsideration given topatient size.The Surflo WingedInfusion Set is a deviceused to administer fluidsfrom a container to apatient's vascular systemthrough a needleinserted in a vein. Theproduct consists of aneedle with attachedtubing and connectors.
OperationPrincipleManualSame

Table 5.3: Summary of Comparative Information

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Image /page/7/Picture/1 description: The image shows the logo for Terumo, a medical device company. The logo consists of a red swoosh above the word "TERUMO" in green, block letters. The swoosh is curved and positioned above and to the left of the word "TERUMO."

DeviceCharacteristicSubject Device: SurfloWinged Infusion SetPredicate: SurfloWinged Infusion Set,K771204
Design /Construction• Needle, needle protector,winged type hub, tubing,connector, connector capSame
Materials• Needle: stainless steel• Needle protector:Polyethylene• Wing: PVC• Tubing: PVC• Connector: PMMA• Connector cap:Polypropylene• Needle: Same• Needle protector:Same• Wing: Same• Tubing: Same• Connector: Same• Connector cap:Polyethylene orPolypropylene
Package• Primary pack• Shelf box• Shipping cartonSame
SpecificationsNeedle Gauge:18G, 19G, 21G, 22G, 23G,25G, 27GNeedle Length (inch):3/4", 1/2"Tubing Length (mm):300, 90, 200Needle Gauge:18G, 19G, 21G, 22G,23G, 25G, 27GNeedle Length (inch):3/4", 1/4", 1/2", 1", 1 1/4"Tubing Length (mm):300, 90, 200
SterilizationEthylene oxide (validatedin accordance with ISO11135 to achieve SAL 10-6)Same
Shelf Life3 yearsSame

Note:

  • . The subject device needle lengths fall within the range of the predicate device's cleared needle lengths. Therefore, the product is substantially equivalent because no new needle lengths were introduced.
  • . The indications for use of the K771204 cleared product is essentially the same as the subject device except for the inclusion of the patient population statement and

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duration for use. The patient population statement was added because the predicate does not identify the intended patient population. This statement aims to direct the user to be mindful of the patient size so the patient can be administered intravenous therapy safely. While the predicate did not specify duration for use, the duration for use was added to clarify the period where the product can be safely used. Although there are wording differences within the statements, the intended use for the subject and the predicate devices are the same.

The Surflo Winged Infusion Set, manufactured by Terumo Medical Products (Hangzhou) Co., Ltd., is substantially equivalent to K771204 Surflo Winged Infusion Set, manufactured by Kofu Factory of Terumo Corporation.

H. NON-CLINICAL TESTS (807.92(b)(1))

Performance

Performance testing was conducted to ensure the Surflo Winged Infusion Set met the predetermined specifications throughout the shelf life, verify conformity to the applicable parts of ISO and non-ISO standards, and demonstrate substantial equivalence to the predicate device. No new issues of safety and effectiveness were raised with the testing performed. The following performance tests were performed on the Surflo Winged Infusion Set:

Table 5.4: Performance Tests

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Image /page/9/Picture/1 description: The image shows the Terumo company logo. The logo consists of a red curved line above the word "TERUMO" in green. The red curved line is positioned above and to the left of the word "TERUMO", creating a sense of motion or direction.

TestStandard
Flow rateGB 18671-2009 Intravenousneedles for single use
Leak testJIS T 3222:2011 Sterilewinged intravenous devices
Wing to tubing connection strength (staticpull force)ISO 8536-4:2019 Infusionequipment for medical use –Part 4: Infusion sets forsingle use, gravity feed
Tubing to connector connection strength(static pull force)ISO 8536-4:2019 Infusionequipment for medical use –Part 4: Infusion sets forsingle use, gravity feed
Needle to wing connection strength (staticpull force)ISO 8536-4:2019 Infusionequipment for medical use –Part 4: Infusion sets forsingle use, gravity feed
Needle curvatureJIS T 3222:2011 Sterilewinged intravenous devices

No deviations from recognized consensus ISO or non-ISO standards were identified in the testing to standards.

Additionally, performance testing other than to the above ISO and non-ISO Standards was performed on the device. The device complies with the acceptance criteria established based on the predicate device:

Performance TestResults
Wing to tubing connection strength (dynamicpull force)Meets acceptance criteria
Tubing to connector connection strength(dynamic pull force)Meets acceptance criteria
Needle to wing connection strength (dynamicpull force)Meets acceptance criteria
Wing-needle protector fitMeets acceptance criteria
Needle penetration resistanceMeets acceptance criteria
Blockage testMeets acceptance criteria

Table 5.5: Additional Performance Tests

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Image /page/10/Picture/1 description: The image shows the logo for Terumo. The logo consists of a red arc above the word "TERUMO" in green. The arc is positioned above and to the left of the word, creating a dynamic and modern look.

Performance TestResults
Priming volumeMeets acceptance criteria

Performance testing demonstrates that the Surflo Winged Infusion Set conforms to the recognized consensus ISO and non-ISO standards, is substantially equivalent to the predicate device, and is acceptable for clinical use throughout the shelf life.

Biocompatibility

In accordance with ISO 10993-1, the Surflo Winged Infusion Set is classified as: Externally Communicating Device, Blood Path, Indirect, Prolonged Contact (>24 hours to 30 days). This classification was chosen as "worst case scenario," and is the same as the Surflo Winged Infusion Set, K771204. The finished device's patient contacting parts were tested in accordance with the tests recommended in FDA Guidance for Industry and Food and Drug Administration Staff – Use of International Standard ISO-10993-1, "Biological evaluation of medical devices – Part 1: Evaluation and testing within a risk management process. " The tests were performed on non-aged (time=0) and accelerated-aged devices to show that biocompatibility is maintained throughout the shelf life of the product. Table 5.6 provides a list of biocompatibility tests conducted on the Surflo Winged Infusion Set.

Non-Aged, Sterile, Whole Device
Cytotoxicity
Sensitization
Intracutaneous Reactivity
Acute System Toxicity
Pyrogenicity
Hemolysis
Subacute/Subchronic Toxicity
Accelerated-Aged (3 Years), Sterile, Whole Device
Cytotoxicity
Sensitization
Intracutaneous Reactivity
Acute System Toxicity
Pyrogenicity
Hemolysis
Subacute/Subchronic Toxicity

Table 5.6: Summary of ISO 10993 Biocompatibility Testing

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Image /page/11/Picture/1 description: The image shows the logo for Terumo. The logo consists of the word "TERUMO" in green, with a red swoosh above the letters "TE". The logo is simple and modern, and the colors are eye-catching.

Results of the testing demonstrate that the device is biocompatible throughout the shelf life of the product.

Sterilization

The sterility of the device is assured using a sterilization method validated in accordance with ISO 11135:2014, Sterilization of health-care products - Ethylene oxide -Requirements for the development, validation and routine control of a sterilization process for medical devices. The Surflo Winged Infusion Set is sterilized to provide a Sterility Assurance Level (SAL) of 10-6.

I. CLINICAL TESTS (807.92(b)(2))

This 510(k) does not include data from clinical tests.

J. CONCLUSION (807.92(b)(3))

In summary, the Surflo Winged Infusion Set, subject of this 510(k), is Substantially Equivalent in its intended use, technology/principal of operation, materials, and performance to the predicate device K771204 – Surflo Winged Infusion Set manufactured by Kofu Factory of Terumo Corporation.

§ 880.5440 Intravascular administration set.

(a)
Identification. An intravascular administration set is a device used to administer fluids from a container to a patient's vascular system through a needle or catheter inserted into a vein. The device may include the needle or catheter, tubing, a flow regulator, a drip chamber, an infusion line filter, an I.V. set stopcock, fluid delivery tubing, connectors between parts of the set, a side tube with a cap to serve as an injection site, and a hollow spike to penetrate and connect the tubing to an I.V. bag or other infusion fluid container.(b)
Classification. Class II (special controls). The special control for pharmacy compounding systems within this classification is the FDA guidance document entitled “Class II Special Controls Guidance Document: Pharmacy Compounding Systems; Final Guidance for Industry and FDA Reviewers.” Pharmacy compounding systems classified within the intravascular administration set are exempt from the premarket notification procedures in subpart E of this part and subject to the limitations in § 880.9.