Decision Summary Assay Only Template

510(k) SUBSTANTIAL EQUIVALENCE DETERMINATION DECISION SUMMARY ASSAY ONLY TEMPLATE

A. 510(k) Number:

k160415

B. Purpose for Submission:

New device

C. Measurand:

Hematocrit (Hct), Total Hemoglobin (tHb), Carboxyhemoglobin (COHb), Methemoglobin (MetHb), Deoxyhemoglobin (HHb), Oxyhemoglobin (O2Hb), Oxygen Saturation (sO2)

D. Type of Test:

Quantitative, electrical conductivity and spectrophotometric method

E. Applicant:

Instrumentation Laboratory Inc.

F. Proprietary and Established Names:

GEM Premier 5000 (Measured parameters: Hematocrit, Total Hemoglobin, Carboxyhemoglobin, Methemoglobin, Deoxyhemoglobin, Oxyhemoglobin, Oxygen Saturation)

G. Regulatory Information:

Product Panel Classification Regulation Section Code 21 CFR 864.5600 GKF Automated hematocrit instrument 21 CFR 864.5620 GKR Automated hemoglobin system Hematology Class II 21 CFR 864.7500 (81) GLY Whole blood hemoglobin assays 21 CFR 864.7425 GHS Carboxyhemoglobin assay

H. Intended Use:

1. Intended use(s):

See Indications for use below

2. Indication(s) for use:

The GEM Premier 5000 is a portable critical care system for use by health care professionals to rapidly analyze heparinized whole blood samples at the point of health care delivery in a clinical setting and in a central laboratory. The instrument provides quantitative measurements of Hematocrit and Total Hemoglobin from venous and arterial heparinized whole blood, as well as quantitative measurements of O2Hb, COHb, MetHb, HHb, sO2 from venous, arterial and capillary heparinized whole blood. These parameters, along with derived parameters, aid in the diagnosis of a patient’s oxygen delivery capacity.

• Hematocrit (Hct) measurements in whole blood of the packed red cell volume of a blood sample are used to distinguish normal from abnormal states, such as anemia and erythrocytosis (an increase in the number of red cells).

• Total Hemoglobin (tHb): Total hemoglobin measurements are used to measure the hemoglobin content of whole blood for the detection of anemia.

• COHb: Carboxyhemoglobin measurements are used to determine the carboxyhemoglobin content of human blood as an aid in the diagnosis of carbon monoxide poisoning.

• MetHb: Methemoglobin measurements are used to determine different conditions of methemoglobinemia.

• HHb: Deoxyhemoglobin, as a fraction of total hemoglobin, is used in combination with oxyhemoglobin to measure oxygenation status.

• O2Hb: Oxyhemoglobin, as a fraction of total hemoglobin, is used in combination with deoxyhemoglobin to measure oxygenation status.

• sO2: Oxygen saturation, more specifically the ratio between the concentration of oxyhemoglobin and oxyhemoglobin plus deoxyhemoglobin, is used to measure oxygenation status.

3. Special conditions for use statement(s):

For prescription use only at point-of-care and central laboratory settings

4. Special instrument requirements:

GEM Premier 5000 analyzer

I. Device Description:

The GEM Premier 5000 system contains two key components: the GEM Premier 5000 analyzer and the GEM Premier 5000 PAK (cartridge). The GEM Premier 5000 PAK contains reagents, sensors, optical cell for Co-Ox and total bilirubin, sampler and waste bag. It enables analysis of 75 to 600 samples per cartridge. There are five process control solutions (A, B, C, D and E), one reference electrode solution and one lysing solution in each GEM Premier 5000 PAK. The five process control solutions are utilized each day at different frequencies to confirm sensor, CO‐Ox and PAK performance.

The target values of the Process Control Solutions for the CO-Ox parameters are stated in the following table: Analyte D E tHb (g/dL) 7.4 16.5 O2Hb (%) 79.9 49.8 COHb (%) 4.0 10.1 MetHb (%) 3.9 8.0 HHb (%) 12.2 32.1 sO2 (%) 86.8 60.8 Hct (%) 27 37

J. Substantial Equivalence Information:

1. Predicate device name(s):

GEM Premier 4000

2. Predicate 510(k) number(s):

K133407 (for GEM Premier 4000)

3. Comparison with predicate:

Item GEM Premier 5000 for the measurement of Hct, GEM Premier 4000 for tHb, O2Hb, COHb, MetHb, HHb, SO2 the measurement of Hct, (Candidate Device k160415) tHb, O2Hb, COHb, MetHb, HHb, SO2 (Predicate Device K133407) Similarities Intended Use A portable critical care system for use by health Same care professionals to rapidly analyze whole blood samples at the point of health care delivery in a clinical setting and in a central laboratory.

Item GEM Premier 5000 for the measurement of Hct, GEM Premier 4000 for tHb, O2Hb, COHb, MetHb, HHb, SO2 the measurement of Hct, (Candidate Device k160415) tHb, O2Hb, COHb, MetHb, HHb, SO2 (Predicate Device K133407) The instrument provides quantitative measurements of Hct, tHb, O2Hb, COHb, MetHb, HHb, SO2 Intended User Central Laboratory and Point‐of‐Care sites Same Types of Quantitative, conductivity, and Same Measurements spectrophotometric Sampling Normal Mode 150 μL Same Modes and Micro Mode 65 μL Sample tBili/CO-Ox Mode 100 µL Volumes Differences Sample Type Hct, tHb: Arterial or venous heparinized whole Heparinized whole blood blood. 02Hb, COHb, MetHb, HHb, sO2: Arterial, venous or capillary heparinized whole blood Measuring Hematocrit:15 to 72% Hematocrit: Same Range tHb: 3.0 to 23.0 g/dL tHb: Same O2Hb: 0.7 to 100.0% O2Hb: 0.0 to 98.0% COHb: 0.3to 75.0% COHb: 0.0 to 99.0% MetHb: 0.7 to 30.0% MetHb: 0.0 to 28.0% HHb: 1.0 to 100.0% HHb: 0.0 to 96.0% sO2: 0.7 to 100.0% sO2: 0.0 to 100.0% Instrument GEM Premier 5000 Instrument: GEM Premier 4000 Dimensions · Height: 18.6 inches Instrument: · Width: 13.0 inches · Height: 18 inches · Depth: 16.4 inches · Width: 12 inches · Weight: 45.4 pounds · Depth: 15 inches · Weight: 44 pounds Intelligent Quality iQM2 iQM Management Name Error Multi‐level checks for detecting cartridge errors, Same except without Detection including IntraSpect checks Scheme in 1. System checks Intelligent 2. Sensor/CO‐Ox checks Quality 3. IntraSpect checks Management 4. Pattern Recognition checks 5. Process Stability checks

Item GEM Premier 5000 for the measurement of Hct, GEM Premier 4000 for tHb, O2Hb, COHb, MetHb, HHb, SO2 the measurement of Hct, (Candidate Device k160415) tHb, O2Hb, COHb, MetHb, HHb, SO2 (Predicate Device K133407) Process 5 PCSs (A,B,C,D,E) 4 PCSs (A,B,C,D) Control Solutions Same formulation for (PCS) in PCSs A, B, and C GEM PAK (cartridge)

K. Standard/Guidance Document Referenced (if applicable):

CLSI - EP05-A3 Evaluation of Precision of Quantitative Measurement Procedures CLSI - EP06-A Evaluation of Linearity of Quantitative Measurement Procedures CLSI - EP07-A2. Interference Testing in Clinical Chemistry CLSI - EP09-A3 Measurement Procedure Comparison and Bias Estimation Using Patient Samples CLSI - EP17-A2 Evaluation of Detection Capability for Clinical Laboratory Measurement Procedures CLSI – EP25-A Evaluation of Stability of In Vitro Diagnostic Reagents

L. Test Principle:

Hct: Hematocrit is measured by an electrical conductivity technique. The conductivity technique is based on the principle that because plasma is more conductive than blood cells due to the high resistance of the cell membranes, the resistivity of blood will increase as the concentration of cells increases. This relationship is expressed by the Maxwell‐Fricke equation: r = Rp x (1 + Hct/100)/(1‐Hct/100), where “r” is the blood resistivity, Rp is a constant based on the plasma resistivity, and Hct is hematocrit. The electrode chamber contains a miniature conductivity cell. By applying an alternating potential through the cell, the resistance of the fluid in the cell can be determined by means of Ohm’s Law.

CO-OX: CO-Oximetry (tHb, O2Hb, COHb, MetHb, HHb and sO2) is based on an optical absorbance measurement of the sample. An in‐line optical cell is integrated in the flow path of the hemolyzed sample to provide a measure of hemoglobin and its derivatives. The optical cell is a flow through channel with two parallel plate optical windows separated by a well‐defined path length. The chemical lysing of the sample is implemented to minimize the scattering effect of the blood and to make the spectral measurement more reliable. The optical measurement hardware, consisting of a white light‐emitting diode (LED) light source, a neon reference and a high resolution spectrometer with a holographic diffraction grating and a charge‐coupled device (CCD) array, are all contained in the analyzer. Only the optical cell is located in the disposable cartridge (GEM PAK) and is aligned with the analyzer optics for spectral measurements following installation of the GEM PAK.

Oxygen saturation (sO2) is a calculated value, more specifically, the ratio between the concentration of oxyhemoglobin and oxyhemoglobin plus deoxyhemoglobin.

Lithium heparin whole blood sample drawn from the patient is measured by using one of the three modes below: Normal mode (150 μL), micro mode (65 μL), or tbili/CO-OX mode (100 μL). Both syringe and capillary samples can be used in normal mode, while only capillary samples can be used in micro mode. The tbili/CO-OX mode is for measuring bilirubin and CO‐Oximetry analytes only.

M. Performance Characteristics (if/when applicable):

1. Analytical performance:

a. Precision/Reproducibility:

Both Internal and External Precision studies were performed in accordance with CLSI EP05-A3 guidance.

Internal Precision Studies:

1) An internal 20-day precision study was performed on the GEM Premier 5000 with GEM System Evaluator 1, 2 and 3. Each of the control levels was run on 3 GEM Premier 5000 analyzers for 20 days, with 2 runs per day and 1 replicate measured per run per level. Results are summarized below:

System Within Within Mean Total Analyte Evaluator N Analyzer Analyzer Total %CV SD Level SD %CV tHb 1 120 20.8 0.14 0.7% 0.16 0.8% (g/dL) 2 120 14.6 0.13 0.9% 0.18 1.2% 3 120 7.8 0.13 1.7% 0.16 2.1% O2Hb 1 120 37.3 0.00 0.0% 0.00 0.0% (%) 2 120 73.7 0.04 0.1% 0.05 0.1% 3 120 93.0 0.04 0.0% 0.05 0.1% COHb 1 120 31.7 0.03 0.1% 0.04 0.1% (%) 2 120 16.8 0.05 0.3% 0.06 0.3% 3 120 3.1 0.07 2.3% 0.09 2.8% MetHb 1 120 8.3 0.05 0.6% 0.09 0.7% (%) 2 120 2.6 0.06 2.5% 0.08 3.1% 3 Not Applicable HHb 1 120 22.6 0.05 0.2% 0.05 0.2% (%) 2 120 6.9 0.05 0.7% 0.06 0.9% 3 120 3.3 0.09 2.6% 0.11 3.2%

System Within Within Mean Total Analyte Evaluator N Analyzer Analyzer Total %CV SD Level SD %CV sO2 1 120 62.2 0.05 0.1% 0.05 0.1% (%) 2 120 91.4 0.06 0.1% 0.07 0.1% 3 120 96.6 0.09 0.1% 0.11 0.1% Hct 1 120 21 0.2 1.2% 0.3 1.3% (%) 2 120 41 0.2 0.6% 0.2 0.6% 3 120 65 0.4 0.6% 0.4 0.6%

2) In addition, an internal precision study was performed using five levels of lithium heparin whole blood samples under normal mode (150 μL) for Hematocrit(Hct), Total Hemoglobin(tHb), Carboxyhemoglobin(COHb), Methemoglobin(MetHb), Deoxyhemoglobin(HHb), Oxyhemoglobin(O2Hb), Oxygen Saturation(sO2) and micro capillary (65 μL) mode for Carboxyhemoglobin(COHb), Methemoglobin(MetHb), Deoxyhemoglobin(HHb), Oxyhemoglobin(O2Hb), Oxygen Saturation(sO2). Due to the instability of whole blood, fresh whole blood samples were prepared each day. Testing was completed in 8 replicates per run for each level and 1 run per day for 5 days on 3 GEM Premier 5000 instruments. Results are summarized below:

Within Run Total CV%* Analyte Mode Level Mean N %CV or SD or Total SD Normal 1 18 120 1.9% 2.5% Mode 2 33 120 1.0% 1.9% Hct (%) 3 45 120 1.0% 1.8% 4 57 120 1.1% 1.8% 5 65 120 1.1% 1.4% Normal 1 6.2 120 0.6% 1.1% Mode 2 11.2 120 0.4% 1.3% tHb (g/dL) 3 15.1 120 0.3% 1.3% 4 18.8 120 0.3% 1.2% 5 21.7 120 0.4% 1.1% Normal 1 9.1 120 0.21 0.22 Mode 2 38.4 120 0.26 0.26 3 77.0 120 0.20 0.21 4 90.6 120 0.21 0.23 5 96.4 120 0.18 0.20 O Hb(%) 2 tBili/ 1 8.7 120 0.20 0.25 CO-Ox 2 38.0 120 0.27 0.29 Mode 3 76.5 120 0.23 0.34 4 90.2 120 0.22 0.33 5 96.0 120 0.21 0.31

Normal 1 1.6 120 0.14 0.22 Mode 2 5.6 120 0.16 0.21 3 15.3 120 0.17 0.23 4 30.3 120 0.21 0.26 5 64.3 120 0.26 0.31 COHb (%) tBili/ 1 1.8 120 0.18 0.29

CO-Ox 2 5.8 120 0.16 0.24 Mode 3 15.4 120 0.20 0.26 4 30.4 120 0.23 0.31 5 64.3 120 0.31 0.46 1 5.0 120 3.4% 4.4% 2 9.9 120 1.9% 2.1% Normal 3 14.5 120 1.9% 2.0% Mode 4 25.5 120 1.1% 1.2% 1 5.0 120 3.4% 4.4% MetHb (%) 1 5.1 120 3.2% 3.7% tBili/ 2 10.0 120 2.1% 2.2% CO-Ox 3 14.8 120 2.3% 2.4%

Mode 4 25.6 120 0.8% 0.8%

1 5.1 120 3.2% 3.7% 1 6.6 120 3.5% 4.6% Normal 2 20.5 120 1.2% 2.1% Mode 3 59.9 120 0.5% 0.8% 4 90.0 120 0.2% 0.4% HHb (%) 1 6.8 120 3.8% 7.4% tBili/ 2 20.9 120 1.2% 2.3% CO-Ox 3 60.2 120 0.5% 1.0% Mode 4 90.1 120 0.3% 0.6% 1 9.2 120 2.3% 2.3% 2 39.0 120 0.7% 0.8% Normal 3 79.0 120 0.3% 0.5% Mode 4 93.2 120 0.3% 0.3%

5 98.7 120 0.2% 0.4% sO2 (%) 1 8.8 120 2.2% 2.8% tBili/ 2 38.7 120 0.7% 0.9% CO-Ox 3 78.6 120 0.3% 0.6% Mode 4 92.9 120 0.3% 0.5% 5 98.5 120 0.3% 0.4%

* The day-to-day contribution was excluded in total precision evaluation for whole blood samples since different whole blood samples were prepared each day.

** The candidate device is not intended for the measurement of Hct and tHb in capillary samples; therefore, only data from syringe samples tested under normal mode for Hct and tHb are shown in the table.

External Precision Studies:

3) A reproducibility study was performed at 3 external clinical point-of-care (POC) sites. The studies were run by a total of 9 different operators (perfusionists and respiratory therapists) on 3 different GEM Premier 5000 instruments using a single lot of GEM Premier 5000 PAK (cartridge). Each site used the same lots of GEM System Evaluator (GSE) 1, 2 and 3, running each control level in triplicate, twice a day for 5 days, for a total of 30 replicates per level per site. The pooled repeatability and reproducibility results for these 3 POC sites are summarized below:

Analyte Level N Mean Repeatability Reproducibility SD %CV SD %CV Hct (%) GSE 1 90 21 0.0 0.0% 0.0 0.0% GSE 2 90 41 0.0 0.0% 0.0 0.0% GSE 3 90 66 0.3 0.4% 0.6 0.9% tHb GSE 1 90 20.7 0.14 0.7% 0.16 0.8% (g/dL) GSE 2 90 14.5 0.10 0.7% 0.13 0.9% GSE 3 90 7.7 0.10 1.3% 0.10 1.4% O Hb 2 GSE 1 90 37.3 0.01 0.0% 0.01 0.0% (%) GSE 2 90 73.7 0.04 0.0% 0.05 0.0% GSE 3 90 93.0 0.03 0.0% 0.04 0.1% COHb GSE 1 90 31.7 0.04 0.1% 0.05 0.2% (%) GSE 2 90 16.8 0.04 0.2% 0.04 0.3% GSE 3 90 3.2 0.06 1.9% 0.07 2.1% MetHb GSE 1 90 8.3 0.05 0.6% 0.06 0.7% (%) GSE 2 90 2.5 0.04 1.7% 0.06 2.4% GSE 3 Not Applicable HHb (%) GSE 1 90 22.6 0.04 0.2% 0.06 0.2% GSE 2 90 6.9 0.05 0.7% 0.06 0.8% GSE 3 90 3.4 0.06 1.9% 0.08 2.3% sO (%) 2 GSE 1 90 62.2 0.04 0.1% 0.06 0.1% GSE 2 90 91.4 0.05 0.1% 0.07 0.1% GSE 3 90 96.5 0.06 0.1% 0.08 0.1%

4) To evaluate whole blood imprecision on the new GEM Premier 5000 system in the central laboratory and point-of-care (POC) sites in hospital settings, whole blood patient samples were tested at 2 external central laboratories and 1 internal

Customer Simulation Laboratory, as well as at 3 external POC locations. For the central laboratory setting, the studies were performed by 3 operators on 3 GEM Premier 5000 instruments using a single lot of GEM Premier 5000 PAK (cartridge). For the POC Setting, the studies were performed by 11 operators on 3 GEM Premier 5000 instruments, using a single lot of GEM Premier 5000 PAK (cartridge). At least two whole blood specimens were analyzed in triplicate daily for 5 days in both normal mode (150 μL) for Hematocrit(Hct), Total Hemoglobin(tHb), Carboxyhemoglobin(COHb), Methemoglobin(MetHb), Deoxyhemoglobin(HHb), Oxyhemoglobin(O2Hb), Oxygen Saturation(sO2) and micro capillary (65 μL) mode for Carboxyhemoglobin(COHb), Methemoglobin(MetHb), Deoxyhemoglobin(HHb), Oxyhemoglobin(O2Hb), Oxygen Saturation(sO2). Due to the use of unique whole blood samples at each clinical site, only repeatability can be evaluated. Reproducibility was not assessed for the whole blood samples. At the internal Customer Simulation Laboratory, contrived whole blood specimens were analyzed in addition to native specimens in order to cover the low and high medical decision levels of each analyte.

The Precision results are summarized below:

Analyte Mode Site N mean Within sample SD Hct (%) Normal POC1 54 27 0.3 Mode POC2 42 26 0.6 POC3 30 28 0.7 POC All 126 27 0.5 CSL 36 44 0.5 Lab1 30 28 0.4 Lab2 30 35 0.5 Lab All 96 36 0.5 tHb (g/dL) Normal POC1 54 8.9 0.10 Mode POC2 42 9.4 0.15 POC3 30 9.6 0.15 POC All 126 9.2 0.13 CSL 33 13.5 0.05 Lab1 30 9.5 0.07 Lab2 30 11.5 0.05 Lab All 93 11.6 0.06 POC1 54 86.5 0.57 POC2 42 93.2 0.31 POC3 30 94.2 0.48 O2Hb (%) Normal POC All 126 90.6 0.48 Mode CSL 30 76.7 0.27 Lab1 30 81.4 0.73 Lab2 30 81.7 0.65 Lab All 90 79.9 0.59 10

Analyte Mode Site N mean Within sample SD POC1 45 91.2 1.00 POC2 39 88.5 0.49 POC3 30 97.0 0.31 tBili/ POC All 114 91.8 0.71 CO-Ox CSL 30 77.2 0.30 Mode Lab1 30 74.6 0.49 Lab2 30 87.6 0.96 Lab All 90 79.8 0.65 POC1 54 2.6 0.31 POC2 42 1.8 0.19 POC3 30 1.7 0.19 Normal POC All 126 2.1 0.25 Mode CSL 36 3.3 0.15 Lab1 30 1.6 0.16 Lab2 30 1.3 0.16 COHb Lab All 96 2.2 0.16 (%) POC1 45 2.6 0.32 POC2 39 1.9 0.21 POC3 30 1.6 0.20 tBili/ POC All 114 2.1 0.26 CO-Ox CSL 36 3.3 0.10 Mode Lab1 30 1.4 0.19 Lab2 30 1.6 0.18 Lab All 96 2.2 0.16 POC1 9 1.6 0.22 Normal POC2 36 1.2 0.16 Mode MetHb POC All 45 1.3 0.17 (%) tBili/ POC1 21 1.3 0.25 CO-Ox POC2 33 1.5 0.27 Mode POC All 54 1.4 0.27 POC1 24 23.1 0.84 POC2 15 10.0 0.41 POC3 15 6.7 0.53 Normal POC All 54 13.3 0.66 Mode CSL 30 21.1 0.34 Lab1 27 18.4 0.69 HHb (%) Lab2 15 32.6 0.81 Lab All 72 24.0 0.60 POC1 15 15.4 1.63 tBili/ POC2 21 14.7 0.58 CO-Ox POC All 36 15.0 1.14 Mode CSL 30 20.5 0.30 Lab1 24 29.2 1.32

Analyte Mode Site N mean Within sample SD Lab2 21 14.9 0.60 Lab All 75 21.5 0.80 POC1 54 89.4 0.63 POC2 42 96.0 0.28 POC3 30 96.3 0.46 Normal POC All 126 93.2 0.50 Mode CSL 30 78.5 0.34 Lab1 30 83.0 0.70 Lab2 30 83.3 0.61 Lab All 90 81.6 0.57 sO (%) 2 POC1 45 94.5 1.04 POC2 39 91.5 0.53 POC3 30 99.1 0.32 tBili/ POC All 114 94.7 0.74 CO-Ox CSL 30 79.1 0.30 Mode Lab1 30 76.2 0.55 Lab2 30 89.4 1.06 Lab All 90 81.6 0.71

* The candidate device is not intended for the measurement of Hct and tHb in capillary samples; therefore, only data from syringe samples tested under normal mode for Hct and tHb are shown in the table. b. Linearity/assay reportable range:

The linearity studies were performed followed the CLSI EP06-A guidance. For hematocrit, total hemoglobin, O2Hb, COHb, MetHb, and HHb, eight levels or more per analyte were prepared by spiking or diluting lithium heparin lithium heparin whole blood from healthy volunteers to challenge the claimed measuring measurement range for each parameter. Three replicates were measured on three (3) GEM Premier 5000 analyzers for each sample. The mean of these replicates was compared to those obtained on the reference analyzers. The linear regression results support the claimed measuring ranges, as summarized in the table below: Note: Combined data from limit of quantitation (LOQ) and linearity studies were used to support lower limit of the claimed reportable range.

# of N per Tested Reportable Analyte Slope Intercept R2 Levels Level Range Range Hct 9 9 0.970 1.904 0.998 7 to 82 15 to 72 (%) tHb 9 9 1.015 0.130 0.999 2.1 to 27.0 3.0 to 23.0 (g/dL) O2Hb 8 9 1.002 0.918 1.000 0.3 to 99.3 0.7 to 100.0 (%)

COHb 8 9 1.016 1.532 1.000 7.4 to 98.5 0.3 to 75.0 (%)* 5 120 1.004 -0.109 1.000 -0.08 to 10.2

MetHb 9 9 1.035 0.029 1.000 3.3 to 38.9 0.7 to 30.0 (%)* 5 120 0.988 -0.149 1.000 0.3 to 9.9 HHb 8 9 1.004 -0.384 1.000 -0.01 to 99.6 1.0 to 100.0 (%) *Additional results at the low-end against the predicate device.

c. Traceability, Stability, Expected values (controls, calibrators, or methods):

Traceability

The GEM Premier 5000 tHb measurement is traceable to Hemiglobincyanide by colorimetry using CyanMetHb standards prepared per CLSI H15-A3 specifications.

The GEM Premier 5000 Hct traceability is achieved by centrifugation using whole blood for establishing true correlation per CLSI H7-A3 guideline. Maintained from lot to lot by controlling conductivity through controlling sodium levels.

d. Detection limit:

The Limit of Blank (LoB), Limit of Detection (LoD) and Limit of Quantification (LoQ) were evaluated in accordance with CLSI EP17-A2 Guideline.

Samples tested were all lithium heparin whole blood samples. LoB was determined by running three blank samples in 60 replicates per day over 3 days using 3 lots of GEM Premier 5000 PAKs (cartridges) on 3 different GEM Premier 5000 instruments. LoD and LoQ were determined by running low level samples in 60 replicates per day over 3 days using 3 lots of GEM Premier 5000 PAKs (cartridges) on 3 different GEM Premier 5000 instruments. LoD is calculated based on LoB (mean) + 1.65 SD (low sample). LoQ was defined as the lowest concentration at which measured total error is less than the pre-defined total allowable error. The results are summarized in the table below:

Analyte LoB LoD LoQ Hct (%) 4 4 7 tHb (g/dL) 0.2 0.3 1.3 O2Hb (%) 0.5 0.7 0.7 COHb (%) 0.1 0.3 0.3 MetHb (%) 0.4 0.7 0.7 HHb (%) 0.5 1.0 1.0

The claimed measuring range of the assays is summarized in the tables below:

Analyte Claimed Measuring Range tHb (%) 3.0-23.0 O2Hb (%) 0.70-100.0 COHb (%) 0.3-75.0 MetHb (%) 0.7-30.0 HHb (%) 1.0-100.0 Hct (%) 15-72 e. Analytical specificity:

Interference studies were performed according to CLSI EP-7A2. Various concentrations of interferents were spiked into two levels (low and high) of each analyte. Testing was performed in singlet per level using 3 GEM Premier 5000 analyzers. The sponsor’s definition of non-significant interference for each analyte was as follows:

Analyte Unit Definition of non-significant interference tHb g/dL ±0.7 O2Hb % ±3.0 COHb % ±2.0 MetHb % ±2.0 HHb % ±3.0 sO2 % ±3.0 Hct % ±4

The highest concentration tested that shows non-significant interference are summarized below:

Tested analytes with no Substance Concentration observed interference

Bilirubin 20 mg/dL tHb/Hb fractions/ sO2 Biliverdin 4 mg/dL tHb/Hb fraction/ sO2 Evans Blue 10 mg/L tHb/Hb fractions/ sO2 78% Fetal Hemoglobin tHb/Hb fractions /sO2

Indocyanine Green 10 mg/L tHb/Hb fractions/ sO2 Leukocytes 44.43 x 103/μL Hematocrit Methylene Blue 20 mg/L tHb/Hb fractions/ sO2 Platelets 785.0 x 103/ μL Hematocrit Sulfhemoglobin 10% tHb/Hb fractions/ sO2 Turbidity 2006 mg/dL Hct / tHb/Hb fractions/ sO (Intralipid) 2

The following table lists substances that demonstrated interference with hematocrit results, causing a significant bias and the concentration of the interfering substance: Lowest Bias Interfering Bias Interfering Observed Interfering Affected Analyte Conc. Observed Conc. with at the Substance Analyte Conc. Tested (Mean) Analyte Lowest Impact Conc.

30% 45.00 g/L +4% 43.92 g/L +4% Albumin Hct 62% 60.00 g/L +5% 49.90 g/L +4%

The following table lists substances that demonstrated interference with CO‐Oximetry results causing a significant bias and the concentration of the interfering substance as well as the bias and its direction (positive / negative):

Lowest Bias Interfering Bias Interfering Observed Interfering Affected Analyte Conc. Observed Conc. with at the Substance Analyte Conc. Tested (Mean) Analyte Lowest Impact Conc.

tHb 10.2 g/dL +0.7 g/dL <|0.7| g/dL O2Hb 84.8% -4.1% -3.0% COHb 9.6% -2.0% <|2.0|% 0.53 g/L 0.45 g/L MetHb 5.0% -2.0% <|2.0|% HHb <1.0% <|3.0|% <|3.0|% Cyanocobalamin sO2 99.3% <|3.0|% <|3.0|% tHb 19.0 g/dL O2Hb 97.2% COHb 1.5% 0.7 g/L No Interference Observed MetHb <0.7% HHb <1.0% sO2 99.2%

tHb 10.2 g/dL <|0.7|g/dL <|0.7| g/dL O2Hb 97.3% <|3.0|% <|3.0|% COHb 1.3% <|2.0|% <|2.0|% 4.0% 3.8% MetHb 0.7% <|2.0|% <|2.0|% HHb <1.0% +3.5% +3.0% sO2 99.3% -3.1% <|3.0|% Cyano- methemoglobin tHb 20.1 g/dL O2Hb 97.5% COHb 1.8% 4.0% No Interference Observed MetHb <0.7% HHb <1.0% sO2 99.9%

Lowest Bias Interfering Bias Interfering Observed Interfering Affected Analyte Conc. Observed Conc. with at the Substance Analyte Conc. Tested (Mean) Analyte Lowest Impact Conc.

tHb 9.5 g/dL +0.7 g/dL <|0.7| g/dL O2Hb 84.8% -5.2% <|3.0|% COHb 10.0% <|2.0|% -2.0% 0.50 g/L 0.34 g/L MetHb 4.5% +2.6% <|2.0|% HHb <1.0% -3.9% <|3.0|% sO2 99.3% +3.5 % <|3.0|% Hydroxocobalamin tHb 19.6 g/dL +0.8 g/dL +0.7 g/dL O2Hb 97.6% -3.4% <|3.0|% COHb 1.5% <|2.0|% <|2.0|% 1.00 g/L 0.83 g/L MetHb <0.7% <|2.0|% <|2.0|% HHb <1.0% <|3.0|% <|3.0|% sO2 99.9% <|3.0|% <|3.0|%

The sponsor also listed the following limitations in their labeling: Condition Result Under-Heparinized Sample Due to Using Blood clot can form in the sensor chamber Non-Heparinized Sampling Devices or causing various sensor failures if sample is Inadequate Mixing with Heparinized not properly heparinized. Devices. Over-Heparinized Sample Due to under Over Heparinization can cause bias in Na+, filling Heparinized Sampling Device or iCa and Hct results. Transferring Heparinized Sample to a Second Heparinized Sampling Device Improper Mixing Errors will be introduced for measurement of hematocrit, total bilirubin and CO-Ox parameters if the sample is not properly mixed prior to measurement.

f. Assay cut-off:

Not Applicable

2. Comparison studies:

a. Method comparison with predicate device:

Method comparison studies were performed following CLSI EP9-A3 at three external representative point-of-care sites using <15% spiked samples to cover the claimed measuring ranges. The regression results for both arterial and venous samples on the syringe mode are presented below:

(Syringe samples) Sample Analyte N Slope Intercept r Range Hct(%) 490 1.003 -0.016 0.997 15 to 70 tHb(g/dL) 496 1.021 -0.055 0.998 3.1 to 22.8 O2Hb(%) 496 1.003 0.338 0.999 12.2 to 99.0 COHb(%) 485 1.000 -0.198 0.998 0.3 to 73.8 MetHb(%) 297 1.000 -0.100 0.997 0.7 to 29.9 HHb(%) 258 1.007 -0.303 0.999 1.0 to 98.7 sO2(%) 494 0.998 0.355 0.999 12.3 to 100

Another method comparison study for capillary whole blood was performed at an external POC site in a hospital and an internal laboratory. Capillary whole blood specimens were collected via capillary puncture into 2 capillary tubes containing lithium heparin, and tested immediately on GEM4000 (predicate) and GEM5000 (new device). In addition, <20% of altered capillary samples were tested internally to cover the claimed measuring ranges. The study results are summarized below:

Analyte r Sample N Slope Intercept Range O2Hb % 182 1.000 0.802 0.997 13.7-98.6 COHb % 180 0.988 -0.269 0.999 0.3-73.8 MetHb % 98 1.000 -0.100 0.998 0.7-29.7 HHb % 181 1.001 -0.279 0.998 1.3-98.5 sO2 % 180 0.994 0.930 0.997 13.9-100.0

Results based on native capillary samples at Medical Decision Level (MDL) are shown below:

Range Range Bias at 95% CI of Bias Analyte N MDL Min Max MDL at MDL

O2Hb (%) 152 84.9 97.4 90.0 1.19 0.48 to 1.89

151 0.3 7.6 3.0 -0.31 -0.49 to -0.12

COHb(%) 10.0* NA NA 180 0.3 73.8 15.0* NA NA

5.0* NA NA MetHb(%) 98 0.7 29.7 10.0* NA NA

HHb (%) 151 1.3 13.9 6.0 -0.56 -1.07 to -0.04

sO2 (%) 152 86.0 99.1 90.0 1.20 -0.06 to 2.45

*There were an insufficient number of native samples to cover these MDLs.

b. Matrix comparison:

Not applicable. Sponsor stated that only lithium heparin anticoagulant whole blood is the acceptable sample type to be used for their device.

3. Clinical studies:

a. Clinical Sensitivity:

Not Applicable

b. Clinical specificity:

Not Applicable

c. Other clinical supportive data (when a. and b. are not applicable):

Not Applicable

4. Clinical cut-off:

Not Applicable

5. Expected values/Reference range:

Reference ranges of Hematocrit and CO-Oximetry are cited from literature:

Hematocrit 1: 40-50% (male), 37-47% (female) tHb 1: 12.6-17.4 g/dL (male), 11.7-16.1 g/dL (female) 2 O2Hb : 90.0-95.0 % COHb 3-5: <3.0(nonsmoker), <10.0 (smoker), MetHb 6: 0.0-1.5% HHb 7: 2.0-6.0 % 1 sO2 : 94.0-98.0 %

1. Wu, A., Tietz Clinical Guide to Laboratory Tests, W.B. Saunders Co., St. Louis MO, 4th Edition, 2006: 951-982.

2. Haymond, S., Oxygen Saturation, A guide to laboratory assessment, Clinical Laboratory News, February 2006: 10-12.

3. Hampson, NB, et al. Practice Recommendations in the Diagnosis, Management and Prevention of Carbon Monoxide Poisoning, Am J Respir Crit Care Med, 2012:186:1095-1101

4. Piantadosi, C.A, Carbon Monoxide Poisoning, New England Journal of Medicine (2002), 347 (14): 1054-1055

5. Radford, EP, Blood Carbon Monoxide Levels in Person 3-74 Years of Age: United States, 1976-1980. National Center for Health Statistics, 1982.

6. Burtis, Carl and David Bruns, Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, Elsevier Saunders, 7th edition, 2015: 952-982

7. American Environmental Laboratory: The Laboratory Assessment of Oxygenation: Robert F. Morgan 1993, 5(4), p. 147-153

N. Proposed Labeling:

The labeling is sufficient and it satisfies the requirements of 21 CFR Part 809.10.

O. Conclusion:

The submitted information in this premarket notification is complete and supports a substantial equivalence decision.