K Number
K222791
Device Name
SafeBreak Vascular
Date Cleared
2022-10-16

(31 days)

Product Code
Regulation Number
880.5220
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP AuthorizedThirdparty
Intended Use
SafeBreak® Vascular is intended to separate when is exerted across a peripheral IV administration set. When SafeBreak@ Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter. SafeBreak® Vascular is intended to aid in reduction of peripheral IV mechanical complications requiring IV replacement. SafeBreak® Vascular is intended to be used on peripheral IV catheters in adults and adolescent populations eighteen (18) years of age and older receiving intermittent or continuous infusions with an electronic pump.
Device Description
SafeBreak® Vascular is placed in-line with an intravenous catheter and an intravascular administration set, including any administration set accessories. It separates into two parts when a specified force is applied. The device has been shown to reduce the risk of IV catheter failure(s) requiring IV catheter replacement. When SafeBreak® Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter. SafeBreak® Vascular is provided sterilized by Ethylene Oxide. The product is single use only and is not designed for reprocessing or re-sterilization by the user. The purpose of this special 510(k) is to expand the separation force tolerance of SafeBreak® Vascular to 1-5 lbf.
More Information

No
The device description and intended use focus on a purely mechanical function (separation at a specified force) and do not mention any computational or learning capabilities.

No.

The device's primary function is to physically separate to stop fluid and blood flow, thereby aiding in the reduction of peripheral IV mechanical complications requiring IV replacement. This is a mechanical function to prevent issues, rather than directly treating a disease or condition. While it prevents further complications, it does not provide therapeutic treatment.

No

This device is designed to aid in the reduction of peripheral IV mechanical complications by separating and stopping fluid/blood flow when a specified force is applied, rather than diagnosing a condition.

No

The device description clearly states it is a physical device placed in-line with an IV catheter and administration set, designed to separate under force. It is provided sterilized and is single-use, indicating a hardware component.

Based on the provided information, the SafeBreak® Vascular is not an In Vitro Diagnostic (IVD) device.

Here's why:

  • Intended Use: The intended use clearly states that the device is for use with peripheral IV catheters to aid in the reduction of mechanical complications requiring IV replacement. It focuses on the physical separation of the device to stop fluid and blood flow.
  • Device Description: The description reinforces its function as an in-line device that separates under force to prevent IV catheter failure.
  • Lack of Diagnostic Purpose: There is no mention of the device being used to examine specimens derived from the human body to provide information for diagnostic, monitoring, or compatibility purposes. IVDs are typically used to test blood, urine, tissue, etc., to detect diseases, conditions, or measure substances.

The SafeBreak® Vascular is a medical device designed for a mechanical function within the patient's circulatory system, not for analyzing biological samples outside the body.

N/A

Intended Use / Indications for Use

SafeBreak® Vascular is intended to separate when excessive tension is exerted across a peripheral IV administration set. When SafeBreak® Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter. SafeBreak® Vascular is intended to aid in reduction of peripheral IV mechanical complications requiring IV replacement. SafeBreak® Vascular is intended to be used on peripheral IV catheters in adults and adolescent populations eighteen (18) years of age and older receiving intermittent or continuous infusions with an electronic pump.

Product codes

QOI

Device Description

SafeBreak® Vascular is placed in-line with an intravenous catheter and an intravascular administration set, including any administration set accessories. It separates into two parts when a specified force is applied. The device has been shown to reduce the risk of IV catheter failure(s) requiring IV catheter replacement. When SafeBreak® Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter.

SafeBreak® Vascular is provided sterilized by Ethylene Oxide. The product is single use only and is not designed for reprocessing or re-sterilization by the user.

The purpose of this special 510(k) is to expand the separation force tolerance of SafeBreak® Vascular to 1-5 lbf.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Not Found

Indicated Patient Age Range

adults and adolescent populations eighteen (18) years of age and older

Intended User / Care Setting

Not Found

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Mechanical testing (i.e., Separation Force Testing) of the SafeBreak® Vascular supports the safety and effectiveness of the expansion of the pull force range in the subject device. The pull force range specification was supported by the reference device.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Not Found

Predicate Device(s)

DEN190043

Reference Device(s)

K212064

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

§ 880.5220 Intravenous catheter force-activated separation device.

(a)
Identification. An intravenous catheter force-activated separation device is placed in-line with an intravenous (IV) catheter and an intravascular administration set, including any administration set accessories. It separates into two parts when a specified force is applied. The device is intended to reduce the risk of IV catheter failure(s) requiring IV catheter replacement.(b)
Classification. Class II (special controls). The special controls for this device are:(1) Performance data must be provided to demonstrate clinically acceptable performance for the intended use of the device.
(2) Non-clinical performance testing must demonstrate that the device performs as intended under anticipated conditions of use. The following performance characteristics must be tested:
(i) Separation force testing;
(ii) Validation of anti-reconnect features;
(iii) Air and liquid leakage testing, both before and after separation;
(iv) Luer connection testing;
(v) Flow rate testing;
(vi) Particulate testing; and
(vii) Microbial ingress testing.
(3) The device must be demonstrated to be biocompatible.
(4) Performance testing must demonstrate that the device is sterile and non-pyrogenic.
(5) Performance testing must support the shelf life of the device by demonstrating continued sterility and device functionality over the identified shelf life.
(6) Device labeling must include:
(i) Instructions for use; and
(ii) A discussion of catheter dressings intended to be used with the device.

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Image /page/0/Picture/0 description: The image contains two logos. On the left is the seal of the Department of Health & Human Services - USA. On the right is the logo for the U.S. Food & Drug Administration (FDA). The FDA logo has the letters FDA in a blue square, followed by the words "U.S. FOOD & DRUG" in blue, with the word "ADMINISTRATION" underneath.

March 16, 2023

Lineus Medical, LLC % Dawn Norman Partner MRC Global, LLC 9085 E Mineral Circle, Suite 110 Centennial, Colorado 80112

Re: K222791

Trade/Device Name: SafeBreak Vascular Regulation Number: 21 CFR 880.5220 Regulation Name: Intravenous catheter force-activated separation device Regulatory Class: Class II Product Code: QOI

Dear Dawn Norman:

The Food and Drug Administration (FDA) is sending this letter to notify you of an administrative change related to your previous substantial equivalence (SE) determination letter dated October 16, 2022. Specifically, FDA is updating this SE Letter for a correction to the 510(k) Summary as an administrative correction.

Please note that the 510(k) submission was not re-reviewed. For questions regarding this letter please contact Dr. David Wolloscheck, OHT3: Office of GastroRenal, ObGyn, General Hospital and Urology Devices, 301-796-1480, David.wolloscheck@fda.hhs.gov.

Sincerely,

David Walloschek

David Wolloscheck, Ph.D. Acting 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 Quality Center for Devices and Radiological Health

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Image /page/1/Picture/0 description: The image contains two logos. On the left is the Department of Health & Human Services USA logo. On the right is the FDA U.S. Food & Drug Administration logo. The FDA logo is in blue.

October 16, 2022

Lineus Medical, LLC % Dawn Norman Partner MRC Global, LLC 9085 E Mineral Circle, Suite 110 Centennial, Colorado 80112

Re: K222791

Trade/Device Name: SafeBreak Vascular Regulation Number: 21 CFR 880.5220 Regulation Name: Intravenous Catheter Force-Activated Separation Device Regulatory Class: Class II Product Code: QOI Dated: September 15, 2022 Received: September 15, 2022

Dear Dawn Norman:

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,

Payal Patel

Payal Patel 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) K222791

Device Name SafeBreak® Vascular

Indications for Use (Describe)

SafeBreak® Vascular is intended to separate when is exerted across a peripheral IV administration set. When SafeBreak@ Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter. SafeBreak® Vascular is intended to aid in reduction of peripheral IV mechanical complications requiring IV replacement. SafeBreak® Vascular is intended to be used on peripheral IV catheters in adults and adolescent populations eighteen (18) years of age and older receiving intermittent or continuous infusions with an electronic pump.

Type of Use (Select one or both, as applicable)
Prescription Use (Part 21 CFR 201 Subpart D) Over-The-Counter Use (21 CFR 201 Subpart C)Prescription Use (Part 21 CFR 201 Subpart D)Over-The-Counter Use (21 CFR 201 Subpart C)
Prescription Use (Part 21 CFR 201 Subpart D)Over-The-Counter Use (21 CFR 201 Subpart C)

Prescription Use (Part 21 CFR 801 Subpart D)

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

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510(k) Summary K222791

Date Prepared:March 7, 2023
Company:Lineus Medical
179 North Church Ave, Suite 202
Fayetteville, AR 72701
Primary Contact:Dawn Norman
Partner, MRC Global
Phone: 618-604-3064
Dawn.Norman@askmrcglobal.com
Company Contact:Vance Clement
Chief Executive Officer
Lineus Medical
Phone: 901-351-9270
vance@lineusmed.com
Trade Name:
Common Name:SafeBreak® Vascular
Intravenous Catheter Force-Activated Separation Device
Classification:
Regulation Number:
Panel:
Product Code:
Primary Predicate:Class II
21 CFR 880.5220
General Hospital
QOI
DEN190043, SafeBreak® Vascular
Manufacturer: Lineus Medical
Reference Device:K212064, Orchid SRV™
Manufacturer: Linear Health Sciences, LLC

Device Description:

SafeBreak® Vascular is placed in-line with an intravenous catheter and an intravascular administration set, including any administration set accessories. It separates into two parts when a specified force is applied. The device has been shown to reduce the risk of IV catheter failure(s) requiring IV catheter replacement. When SafeBreak® Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter.

SafeBreak® Vascular is provided sterilized by Ethylene Oxide. The product is single use only and is not designed for reprocessing or re-sterilization by the user.

The purpose of this special 510(k) is to expand the separation force tolerance of SafeBreak® Vascular to 1-5 lbf.

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Indications for Use:

SafeBreak® Vascular is intended to separate when excessive tension is exerted across a peripheral IV administration set. When SafeBreak® Vascular separates, fluid flow is stopped from the infusion pump and blood flow is stopped from the patient's IV catheter. SafeBreak® Vascular is intended to aid in reduction of peripheral IV mechanical complications requiring IV replacement. SafeBreak® Vascular is intended to be used on peripheral IV catheters in adults and adolescent populations eighteen (18) years of age and older receiving intermittent or continuous infusions with an electronic pump.

Substantial Equivalence:

The subject SafeBreak® Vascular is intended to separate when excessive tension is exerted across a peripheral IV administration set. The separation force tolerance of SafeBreak® Vascular is being expanded to 1-5 lbf. The subject SafeBreak® Vascular is intended to aid in reduction in peripheral IV mechanical complications requiring IV replacement. The subject SafeBreak® Vascular has the same intended use, same or similar materials, same or similar technological characteristics, the same operating principle, as the predicate and reference devices, respectively.

The safety and effectiveness of the subject device has been verified and validated and are all are substantially equivalent. Thus, it can be concluded that the subject SafeBreak® Vascular does not raise different questions about safety and effectiveness.

K222791DEN190043Assessment of Differences
SubjectPredicate
General Device Characteristics
Indications for
UseSafeBreak® Vascular is intended
to aid in reduction of peripheral
IV mechanical complications
requiring IV replacement.
SafeBreak® Vascular is intended
to be used on peripheral IV
catheters in adults and
adolescent populations eighteen
(18) years of age and older
receiving intermittent or
continuous infusions with an
electronic pump.SafeBreak® Vascular is
intended to aid in reduction of
peripheral IV mechanical
complications requiring IV
replacement.
SafeBreak® Vascular is
intended to be used on
peripheral IV catheters in
adults and adolescent
populations eighteen
(18) years of age and older
receiving intermittent or
continuous infusions with an
electronic pump.Identical; Substantially
Equivalent
Materials• Makrolon
• Polycarbonate
• Saint-Gobain
• INEOS ABS Lustran
• Silicone• Makrolon
• Polycarbonate
• Saint-Gobain
• INEOS ABS Lustran
• SiliconeIdentical; Substantially
Equivalent

Device Comparison

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K222791DEN190043Assessment of Differences
SubjectPredicate
Separation force1-5 lbf$4 \pm 1$ lbfSubstantially equivalent.
Both the predicate and
reference devices have
demonstrated the safety
and effectiveness of
separation forces. The
change in tolerance of the
subject device separation
force does not raise any
different questions of safety
or effectiveness.
Environment of
UseHospitalHospitalIdentical; Substantially
Equivalent
Principle of
OperationThe subject SafeBreak Vascular
connects to the needleless
connector found in the existing
IV extension set and to the
existing IV administration set via
luer connectors. Upon
installation of the SafeBreak
Vascular, infusion can occur.
Upon tension the SafeBreak
Vascular separates and the valve
on each end of the device closes,
stopping flow.The subject SafeBreak Vascular
connects to the needleless
connector found in the existing
IV extension set and to the
existing IV administration set
via luer connectors. Upon
installation of the SafeBreak
Vascular, infusion can occur.
Upon tension the SafeBreak
Vascular separates and the
valve on each end of the
device closes, stopping flow.Identical; Substantially
Equivalent
Vascular Access
TypePeripheral intravenous catheterPeripheral intravenous
catheterIdentical; Substantially
Equivalent
For Use with
Electronic
PumpYesYesIdentical; Substantially
Equivalent
Single UseYesYesIdentical; Substantially
Equivalent
Continuous and
Intermittent
InfusionYesYesIdentical; Substantially
Equivalent

Performance Testing:

Mechanical testing (i.e., Separation Force Testing) of the SafeBreak® Vascular supports the safety and effectiveness of the expansion of the pull force range in the subject device. The pull force range specification was supported by the reference device.

Conclusion:

The subject SafeBreak® Vascular has similar intended use, and identical materials, technological characteristics, and operating principle compared to the predicate device. In addition, performance testing and engineering analysis support the expansion of the separation force specification, compared to the reference device. The difference in technology does not affect the safety and effectiveness of the subject device.

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Therefore, it can be concluded that the subject device is as safe, as effective, and performs at least as safely and effectively as the predicate and reference device.