CancerCare Manitoba stops use of some IV lines after ‘increased risks and concerns’

The provincial cancer agency is halting its use of an infusion pump line, due to concerns over leakage and heightened risk of potentially hazardous chemotherapy drug spills.

In an internal memo, sent Dec. 17, 2024, CancerCare Manitoba recommended community cancer care program directors and managers stop using B. Braun Cyto-Set lines in early 2025.

The specialized infusion lines are designed to deliver chemotherapy drugs to patients intravenously. They are typically secured to an IV pump, which then distributes controlled doses of medication to patients.

“Over the last year, there have been increased risks and concerns brought forward,” the memo said.

According to the memo, the lines are prone to leaking and at risk of spilling chemicals. They also have limited compatibility with other IV equipment, and there are frequent supply shortages.

Shared Health spokesperson Jason Permanand confirmed the health authority signed a service agreement with B. Braun in September 2021 to supply large volume infusion pumps, IV and blood administration sets for service delivery organizations, including CancerCare Manitoba.

Some of that equipment, including specific models of IV pumps, were later involved in a recall, Permanand said in an email.

B. Braun Medical Inc. notified Health Canada on June 12, 2024, about a recall of its Horizon and Infusomat space pumps in both Canada and the United States, spokesperson Tammy Jarbeau said.

“Devices distributed across Canada, including Manitoba, were included in the recall,” Jarbeau said in an email.

“The company reported that the backcheck valve of the device may malfunction, causing a backflow of medication from the secondary IV into the primary IV bag. It may also cause an inability to remove air bubbles from the tubing.”

Health Canada received 259 reports related to the pumps between Dec. 1, 2019, and Feb. 28, 2025. The reports accounted for one death and 16 incidents in which a patient’s health seriously deteriorated, the spokesperson said.

In total, 243 reports came from Manitoba.

The health department would not confirm whether anybody was injured or killed in Manitoba, citing patient privacy.

The CancerCare memo said Infusomat Space large volume infusion pumps have been in use in the province for around a year and a half. B. Braun’s website indicates the pumps can be used for a variety of treatments.

The Cyto-Set lines have not been subject to a recall.

Manitoba Nurses Union president Darlene Jackson said her union is aware of widespread complaints about the equipment across an array of health-care settings.

“We’ve been hearing about this since the very beginning,” Jackson said. “It’s to the point now where it’s causing so much more work and it’s ridiculous.”

Jackson said nurses who use the pumps and lines fear somebody may be inadvertently exposed to the potentially dangerous medications and chemicals used in a variety of medical treatments.

Sensors on the pumps are known to be extremely sensitive and may frequently set off false alarms that make it difficult for nurses to know whether the device isn’t working properly, or whether there is an issue with drug delivery, she said.

“I can tell you nurses are terrified that these pumps are not going to function correctly and they are not going to know,” she said. “You have equipment that you should be able to depend on that is not dependable.”

The union leader said the issues have been raised through labour relations officers and workplace health and safety committees.

She stressed Manitoba health officials are taking the concerns seriously.

Jackson urged nurses to continue reporting incidents through the appropriate channels, so there is thorough documentation of the product’s challenges.

Shared Health reiterated that message in its email statement.

“We are moving quickly to identify these solutions and will continue to communicate with front-line staff so they can continue to deliver the best quality care for our patients,” Permanand said.

Health Canada said B. Braun is resolving issues with the recalled pumps and sent written notifications to the customers and hospitals that received the faulty devices.

Those notifications included specialized instructions for clinicians to allow them to continue to use the pumps until unaffected sets become available, spokesperson Jarbeau said.

“B. Braun also specified that critical medications should not be given through secondary IV lines,” she said.

In an email statement, B. Braun spokesperson Alli Longenhagen said the company deployed a team of clinical educators to provide additional training to staff in the wake of the pump recall.

“The health systems in the province that implemented the recommendations, resolved the issues in question,” Longenhagen said, adding the facilities that continue to struggle with the equipment “have been resistant to implement the solutions.”

She said B. Braun identified two Manitoba hospitals, in particular, that “appear to be struggling and would most benefit from additional education.”

“We maintain that proper training and education will resolve the majority of the issues being raised by the facilities,” Longenhagen said.

Jackson described the training provided by B. Braun as “workarounds” and said the company’s own educators were struggling with the equipment.

She said the suggestion that nurses were simply not using the pumps properly was insulting.

“I can guarantee you that is not true,” Jackson said. “Nurses who were educated on the workarounds have been using the workarounds, but are still having issues with them.”

tyler.searle@freepress.mb.ca