Case B4: Acute Hemolysis During Surgery

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Last Updated: Oct. 28, 2016 [All links fixed]

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Learning Outcomes

Upon completion of this exercise, participants should be able to:

  1. List the temperatures at which RBC, platelets, and fresh frozen plasma should be stored and shipped.
  2. Describe how RBC should be packed for shipping.
  3. List the steps at which blood and blood products should be visually examined.
  4. Provide criteria for examining blood visually.
  5. Discuss the consequences of transfusing hemolyzed RBC.
  6. Discuss the importance of hospital-wide education of staff involved in transfusing patients.
  7. Explain how human errors are handled in a quality system.

Case Report

A 75-year-old female presented with severe abdominal pain and vomiting to a rural hospital (Hospital A). After being diagnosed as having a perforated gastric ulcer, the patient  was transported from Hospital A via air ambulance to Hospital B, a large city hospital. Four units of RBC were shipped with the patient and were taken directly to the operating room.


  • Transfusion: none

  • Pregnancy:one (miscarriage)

  • Medications: Patient reported taking ibuprofen three to four times per week for the past 5 years to treat arthritic pain.

In the Operating Room

  • During the surgery to repair the perforated ulcer, after transfusing 2 units of RBC, with a third in progress, the anesthesiologist noticed that the fourth RBC unit was frozen. The RBC being transfused was stopped immediately.
  • The anesthesiologist checked the tubing and remaining contents of the transfused and partially transfused units. The first unit transfused appeared normal but the other two appeared discoloured, possibly hemolysed.
  • OR staff discovered that the blood had been shipped in a container with dry ice.

Laboratory Findings (Post-Op)

  • The transfusion service was notified and began an investigation for a suspected hemolytic transfusion reaction.
    • The patient's post-transfusion specimen showed gross hemoglobinemia.
    • The patient typed as group A D-positive, with a negative antibody screen and a negative direct antiglobuin test (DAT).
    • Donor units were labelled as group A D-positive but reliable ABO and Rh typing could not be done due to hemolysis. The grossly hemolysed plasma samples from the donor bag segments were tested and found to contain anti-B, as would be expected for group A donors.
    • Crossmatching was not possible due to hemolysis of the donor units. The original hospital faxed a worksheet showing that the units were crossmatch-compatible by LISS-antiglobulin test.
    • One hour post-surgery the patient's urine was red and urinalysis was positive for hemoglobin.

Follow-Up and Case Outcome

  • Investigation revealed that non-laboratory staff from the outlying hospital had shipped the blood in a container with dry ice. Laboratory staff had not been notified. Staff in the OR had not noticed anything unusual when they transferred the RBC from the shipping container to the OR refrigerator.
  • The patient went on to become uremic, hyperkalemic, anuric and died four days later.


See the case discussion, including interactive questions with feedback.

Final Quiz

This quiz is offered as self assessment.

  1. At what temperature should the following blood components be transported?
    1. RBC
    2. Platelets
    3. Fresh frozen plasma and cryosupernatant plasma
  2. Describe how RBC should be packed for shipping.
  3. What are the possible consequences of transfusing RBC that are hemolysing?
  4. At what steps should blood be examined visually in the transfusion service?
  5. Provide 5 criteria for examining blood visually.
  6. How does a quality system deal with human errors?

Further Reading

British Columbia Provincial Blood Coordinating Office. Technical resource manual for hospital transfusion services, ed 2. Vancouver: Provincial Blood Coordinating Office;2006. See IMM.003 (Visual Inspection) and IMM.006 (Interhospital exchange).

Callum, JL, Kaplan, HS, Merkley, L L, Pinkerton, PH, Rabin Fastman, B, Romans, RA.  Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion 2001; 41: 1204-11. [ Medline ]

Canadian Standards Association. Blood and blood components (Z902-15).

Clark P, Rennie I, Rawlinson S. Quality improvement report: Effect of a formal education programme on safety of transfusions. Br Med J 2001 Nov 10;323(7321):1118-20.

Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion 2000;40(10):1207-13.  [ Medline ]

Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. Br Med J 1999;319:16-9.