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This report has been identified as b.Braun medical internal report number (b)(4).A review of the batch history records was performed for the reported lot number, and no abnormalities or non-conformances were noted during the in process or final product inspection.No sample was provided for evaluation.Based on the data from the investigation we are unable to determine the root cause of the reported incident.The reported defect was unable to be confirmed.We will maintain this report for further references and continue to monitor other reports for similar occurrences.If any additional pertinent information becomes available, a follow up will be submitted.
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As reported by the user facility: detail: when attaching the luer lock to the bottle, it was extremely difficult to connect the tubing and establish suction.As a result, the vacuum somehow released, and when this occurred, air from the bottle was pushed into the patient, causing a pneumothorax that required chest tube placement.After that incident, we performed a paracentesis and again were unable to securely connect the luer lock tubing to achieve suction.We attempted this with multiple bottles and were unsuccessful each time.These were the first two patients for whom we had used these bottles.We tried to establish a connection with empty bottles not attached to the patient and successfully got the suction to release once out of five.
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