The bag was retained by the user and sent to charter medical for investigation.The bag was visually inspected; no anomalies were visibly detected.The bag was leak tested by inflating with compressed air - the bag would not remain inflated due to film tear on the front of the bag.The anomaly was characterized as a tear since the film on the edges of the opening had a jagged appearance.The film tear was approximately 0.40-inch long, and was located in the approximate center of the bag.No other issues were observed on the bag.A film tear of the size observed on the returned sample would have likely resulted in a detectable leak, during filling, before the bag was frozen.The root cause of the tear could not be conclusively determined.Since the report of the tear occurred after freezing and during the thawing process, this would suggest the tear likely occurred during handling or transportation of the bag while it was in a frozen condition.The exact point in the handling process where damage may have occurred is unknown.There are other causes that could potentially result in a tear: - overfilling the bag.An overfilled bag could create resistance during insertion and removal of the bag from the metal cassette.- excessive air left inside the bag after filling, resulting in rapid expansion during thawing.- moisture on the exterior surface of the bag or cassette interior when the bag is inserted into the metal cassette.Moisture may cause the bag film to freeze to the interior cassette surface, thus potentially resulting in damage when the frozen bag is removed from the cassette.The product instruction for use sheet is provided with each cml-75ln device.Review of the ifu version provided with lot 141256 has the following precautions: - "after freezing, do not handle excessively.Port tubes and film are fragile in the frozen state and breakage may occur.Handle with care." - "do not overfill." - "remove as much air as possible from the container." - "ensure bag exterior and protective freezing cassettes are dry prior to initiating freezing protocol.Moisture on the exterior of the bag or on the cassette could cause adherence of the bag to the cassette resulting in difficulty of bag removal.".
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