The patient was undergoing a thrombectomy procedure in the m2 segment of the middle cerebral artery (mca)using a penumbra system aspiration pump max 220 (pump max).During the procedure, a hospital staff accidentally connected the aspiration tubing (tubing) directly to the pump max rather than the canister.Consequently, blood was aspirated into the pump max; therefore, the pump max was disconnected.The procedure was completed using another pump max.There was no report of an adverse effect to the patient.
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Results: a pipe cleaner was inserted into the vacuum inlet and blood was found inside the pump assembly.Conclusions: evaluation of the returned pump max confirmed blood was aspirated inside the vacuum pump.The complaint reported that the aspiration tubing was connected directly to the pump max vacuum inlet, rather than the canister supplied by penumbra.If fluid is aspirated into the vacuum assembly, the pump may not function properly.Penumbra pumps are visually inspected and functionally tested during incoming quality inspection.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.
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