Troubleshooting Hemolysis Issues

Hemolysis plagues the clinical laboratory and continues to be a growing concern. It is often the cause of specimen rejection and may be
the source of erroneous patient results. Recollection and subsequent patient treatment delays are costly to healthcare systems. Factors
that contribute to red cell lysis are listed below with suggested corrective actions.

SPECIMEN COLLECTION ISSUES

Possible Factors
Affecting Hemolysis Possible Consequences Corrective Actions
• Venipuncture • Hand veins are fragile and easily traumatized. • The veins in the antecubital area are the veins of choice.1 If it is
necessary to draw distally to the antecubital area, a 22 G or
23 G needle used with a partial draw tube (i.e., has a reduced
vacuum and tube fills “part way” while maintaining the proper
blood-to-additive ratio) is suggested.

• Prolonged tourniquet time • Hemoconcentration. • Release the tourniquet as soon as blood flow is established in the first
• Can affect water balance of cells. RBCs (red blood cells) rupture. tube, if possible. Tourniquet should be released after no more than 1
minute from initial placement.1

• Cleansing procedure with • Performing the venipuncture before the alcohol is allowed to • Allow alcohol to thoroughly dry.1
isopropyl alcohol thoroughly dry may cause the RBCs to rupture.

• Needle readjustment • Vein trauma may result when the needle placement is not • The needle should be parallel to the vein. Enter at a 30° angle or less.1
accurate. • Reposition the needle forward or backward (vertically).1
• Avoid probing.1

• Needle gauge
— Bore too large (= lower gauge) • Blood enters tube faster and more forcefully and may result • Select a needle gauge appropriate for the vein size, location,
Ex. 18 G in hemolysis. and patient condition.1, 2
• Use a partial draw tube.
– Bore too small (= higher gauge) • When used with a full draw tube, the RBCs may rupture
Ex. 25 G due to vacuum force.
• Blood travels through an extremely small opening under a
great force. This may cause the RBC wall to shear.

• Syringe collection • Too much force applied to the plunger during blood collection. • Before use, move the plunger within the barrel of the syringe to
• Blood may begin to clot and hemolyze while being aspirated ensure freedom of movement.1
into a large volume syringe. • Do not use a syringe size much larger than the amount of blood
needed.
• Forceful transfer of blood from the syringe into the blood
collection tube. • Transfer the blood into the tube immediately after venipuncture.
• Use a blood transfer device (BTD).1
• Do not apply force to the plunger during transfer of the blood into
the blood collection tube.
• After attachment to the BTD, angle the syringe. This allows the blood
to flow slowly down the side of the tube wall.3

• Catheter collection • Blood may travel through several different internal diameters • Ensure all connections fit together securely.
(catheter and connectors). The turbulence may cause the cells • Do not mix manufacturers’ components.
to rupture. • Collect discard tube.
• Use partial draw tubes.
• Use extension tubing.
• Increase catheter size.
• Use the BD Vacutainer® Luer-Lok™ Access Device (LLAD)
for all valve ports.

• Needle occlusion • May cause the blood to flow slowly and initiate RBC shearing. • Needle bevel may be positioned against the vein wall. Pull back
slightly on the needle.4
• Avoid rotating or changing the angle of the needle.

• Loose connections of component parts • Air may be introduced into the sample and cause frothing. • Ensure all connections fit together securely.
(i.e., needle to holder, blood collection set This may result in hemolysis. • Do not mix manufacturers’ components.
hub to luer adapter or syringe)

• Tube choice • Tube vacuum might cause the blood to enter the tube • Based upon the condition of the patient’s vein, select a tube with
forcefully and may cause cell rupture. the appropriate amount of vacuum.2
• Use of partial draw tubes helps reduce hemolysis.

• Tube fill volume • Excessive concentrations of additives can cause rupture of the • Fill tubes to their proper draw volume to ensure proper
RBC cell membrane, e.g., oxalate. blood:additive ratio.5

• Hematoma • Specimens collected by penetrating through a hematoma may • Select another site.
cause erroneous test results. • If another site is not available, collect distally to the hematoma.

PROCESSING/HANDLING/TRANSPORT ISSUES
Possible Factors
Affecting Hemolysis Possible Consequences Corrective Actions
• Vigorous mixing • May cause the RBCs to rupture. • Gentle tube inversion, 180° down and up.5, 6

• Rimming clots • Insufficient clotting may cause fibrin formation. • Allow BD SST™ Tubes to clot for at least 30 minutes and plain serum
• Wooden applicator sticks can shred the red cells. tubes for 45 ± 15 minutes in a vertical closure-up position to avoid
fibrin formation.5, 6

• Prolonged contact of serum/plasma • Hemoglobin released from hemolyzed cells will contaminate • Separate serum/plasma from cells within 2 h of collection.5,6
with cells serum/plasma.

• Centrifugation at higher than • Causes lysis of cells. • 1000 -1300 x g for BD SST™ Glass Tubes and 16 mm Plus
recommended g force. Plastic Tubes.
• Increased heat exposure in centrifuge. • 1100-1300 x g for BD Plus SST™ Plastic Tubes.
• Running fixed angle centrifuge continuously • 1500 x g for sodium citrate tubes.
for long periods of time (> 15 minutes) may • Other non-gel tubes < 1300 x g.5
increase the internal temperature.

• Temperatures • RBC membrane may rupture • Keep specimens at room temperature.

– Elevated or Decreased • Chill specimens, if necessary, avoid freezing, unless recommended.6
• Ensure centrifuge temperatures are acceptable.

• Pneumatic tube system • Hemolysis may be due to acceleration and/or deceleration • Hand-deliver specimens when possible.
speed, length of system, angles, and tube cushioning. • Ensure the pneumatic tube system has been tested to certify test
results will not be compromised.6
• Provide adequate inner cushioning for the blood collection tubes
during transport to avoid excessive mixing.

PATIENT FACTORS
Possible Factors
Affecting Hemolysis Possible Consequences Corrective Actions
• Metabolic disorders • May cause red cell lysis.7 • Check patient’s history.
– Liver disease
– Sickle cell anemia
– Autoimmune hemolytic anemia
• Chemical agents • Depending on the dosage, may cause red cell lysis.7 • Check patient’s history.
– Lead
– Sulfonamides
– Antimalarial drugs
– Analgesics
• Physical agents • May cause intravascular hemolysis. • Check patient’s history.
– Mechanical heart valve • Cause direct damage to the RBCs.7
– Third degree burns
• Infectious agents • Fragility of RBCs may increase.7 • Check patient’s history.
– Parasites • Treat patient with appropriate medications.
– Bacteria

RELATIVE HEMOLYSIS SCALE

0 Factors
Possible ~35 ~70 ~140 ~275 ~550 ~1100
Affecting Hemolysis mg/dl

REFERENCES
1. National Committee for Clinical Laboratory Standards. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; 5. BD Vacutainer® Evacuated Blood Collection System product insert, June 2004.
Approved Standard. 5th ed. Wayne, PA: National Committee for Clinical Laboratory Standards; 2003. NCCLS Document H3-A5.
6. National Committee for Clinical Laboratory Standards. Procedures for the Handling and Processing of Blood Specimens; Approved
2. Lemery LD. “Oh, No! It’s Hemolyzed!” What, Why, Who, How? Advance for Med Lab Prof. 1998;24-25. Guideline. 3rd ed. Wayne, PA: National Committee for Clinical Laboratory Standards; 2004. NCCLS Document H18-A3.
3. Stankovic AK, Smith S. Elevated serum potassium values: the role of preanalytic variables. Am J Clin Pathol. 2004;121 7. Henry JB, ed. Todd-Sanford-Davidsohn: Clinical Diagnosis and Management by Laboratory Methods. Vol 1. 16th ed.
(suppl 1):S105-S112. Philadelphia, PA: WB Saunders Co; 1979:1005-1007.
4. Burns ER, Yoshikawa N. Hemolysis in serum samples drawn by emergency department personnel versus laboratory phlebotomists.
Lab Med. 2002;33:378-380.
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