The FDA has identified this as a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death.

Recalled Product

  • Product Names: DeRoyal Procedure Packs containing Smiths Medical NORMOFLO Irrigation Warming Set 
  • Product Codes for CYSTO Pack PGYBK/89-5721.03 and GU TUR BASIN SET PGYBK/89-6425.07: See Recall Database Entry
  • Manufacturing Dates: November 8, 2017 to July 22, 2021
  • Distribution Dates: November 29, 2017 to July 21, 2021 
  • Devices Recalled in the United States: 2,856
  • Date Initiated by Firm: September 2, 2021

Device Use

DeRoyal Industries’ procedure packs include an irrigation warming set that may be used with a fluid warming device. Fluid warming devices may be used by health care providers to:

  • Provide more blood for patients suffering from blood loss due to trauma or surgery.
  • Rewarm patients after surgery to prevent hypothermia.
  • Irrigate during urology procedures.

Reason for Recall  

DeRoyal Industries, Inc. is recalling their procedure packs which contain the recalled Smiths Medical NORMOFLO Irrigation Warming Set because of the potential for aluminum ions to leach into warmed fluids. If this occurs, contaminated fluids can circulate through a patient’s body and the patient can be exposed to high levels of aluminum. Exposure to harmful levels of aluminum may not be easily recognized and the effects could cause serious adverse events including cognitive decline, dementia, nervous system damage, and even death. Patients who have symptoms may experience bone or muscle pain or weakness, anemia, seizures, or coma.

There have been no complaints, injuries, or reports of death for this issue.

Who May be Affected 

  • Pediatric patients, particularly neonates and infants
  • Pregnant women
  • Older adults
  • Patients with poor kidney function or on dialysis

What to Do 

On September 03, 2021, DeRoyal Industries, Inc. sent all affected customers an “Important Medical Device Recall” letter.  

The letter requested customers to:

  1. Identify the affected products.
  2. Complete the notice of credit form provided with the recall notification and return it to DeRoyal Industries, Inc. 
  3. Quarantine the affected products and return them to DeRoyal Industries, Inc.
  4. Forward a copy of the recall notification to any customers who may have further distributed the affected products, asking them to identify, quarantine, and return the affected products to DeRoyal Industries, Inc. 

Contact Information 

Customers with questions about this recall should email [email protected].

Additional Resources: 

How do I report a problem?

Health care professionals and consumers may report adverse reactions or quality problems they experienced using these devices to MedWatch: The FDA Safety Information and Adverse Event Reporting Program using an online form, regular mail, or FAX.