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The customer reported during the red blood cell depletion of allogeneic bone marrow, an incident occurred involving the optia kit required to perform this type of processing.Specifically, the machine displayed the error message "overpressure at the ring", and a leak was observed by the operator.The patient was given prophylactic antibiotic therapy.Due to eu personal data protection laws, the patient information is not available from the customer. .
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Investigation: a review of the device history record (dhr) for this lot showed no irregularities during manufacturing that were relevant to this issue.One used optia idl set was received for investigation.Initial observations noted blood throughout the set and the reservoir was approx.30 % full.Further inspection of the loop noted that there were witness marks on the upper bearing and the ears were adequately snapped into place with no damage on the ears, however there was minimal damage to the bottom of the upper bearing where it looked to have been slightly sheared.Further observations noted blood on the exterior of the braid towards the lower portion of the braid, adjacent to the lower bearing.The ears of the lower bearing were snapped in place; however, the ears did appear sheared.When manipulating the lower bearing, there was white debris under the bearing, and damage.Inspection of the lower bearing did show a witness mark.Further inspection of the sleeve noted a severe crack in the middle, exposing the underlying four lumen.Inspection of the four-lumen noted that the rbc and inlet lines were sheared, identifying the leak pathway and confirming the customers complaint.No other missing leak, missing parts or missasembles were noted. investigation is in process.A follow-up report will be provided.
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