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Zeroing in on the root cause of the clots in a blood bag: Reinforcing

improvement in blood collection practices

Article in Transfusion Clinique et Biologique · April 2021

DOI: 10.1016/j.tracli.2021.04.005

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Short communication

Zeroing in on the root cause of the clots in a blood bag: Reinforcing

improvement in blood collection practices
Manish Raturi a,∗ , Ayushi Kediya b , Mansi Kala c , Adityaveer Sahrawat d
a
Associate Professor, Department of Immunohematology and Blood Transfusion, Himalayan Institute of Medical Sciences, Swami Rama Himalayan
University, Swami Ram Nagar, Jolly Grant Dehradun, 248016 Uttarakhand, India
b
Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Jolly Grant Dehradun, 248016
Uttarakhand, India
c
Associate Professor, Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Jolly
Grant Dehradun, 248016 Uttarakhand, India
d
Technical Supervisor, Department of Immunohematology and Blood Transfusion, Himalayan Institute of Medical Sciences, Swami Rama Himalayan
University, Swami Ram Nagar, Jolly Grant Dehradun, 248016 Uttarakhand, India

a r t i c l e i n f o a b s t r a c t

Article history: Blood clots in the packed red blood cell [PRBC] unit can sometimes go unrecognized and could eventually
Available online 24 April 2021 give rise to flow problems while administering the same. We herein report our observation of a moder-
ately elongated threadlike clot in a PRBC unit prepared from a whole blood donated by a young Indian
Keywords: male donor. The PRBC unit was returned to us from the ward by the nursing staff citing “flow issues”. In
Blood Clots fact, this warranted the initiation of root-cause analysis of the entire event led by two faculty members,
Whole Blood Donation one post-graduate student and the technical supervisor at our blood centre.
Root Causes
© 2021 Société française de transfusion sanguine (SFTS). Published by Elsevier Masson SAS. All rights
Blood Centre
Corrective Action
reserved.
Blood Units

Blood clots in the packed red blood cell [PRBC] unit can some-
times go unrecognized and may give rise to flow problems while
administering the same. We herein report our observation of a 4
to 5 cm moderately elongated threadlike clot in a B Rh (D) posi-
tive PRBC unit, as soon as it was returned to us from the bedside.
In fact, this warranted the initiation of a root-cause analysis [RCA]
of the entire event (Fig. 1). We began by gathering the informa-
tion right from the donor details and then mapping the complete
information to identify the actual cause of the problem with the
various contributing factors. Once all the team members (led by
two faculty, a post-graduate student and the technical supervisor
of our blood centre) agreed on the cause identified, we made a final
report and took corrective action. The appropriate recommenda-
tions for the avoidance of the recurrence of such an event were
proposed too.
In the present case, a whole blood [WB] unit was collected in a
voluntary blood donation camp [VBDC] that was organized within
the vicinity of our blood centre. Further, according to the campsite
∗ Corresponding author.
E-mail address: manishraturi@srhu.edu.in (M. Raturi).
technician who had performed the phlebotomy on a young Indian
male donor, “amid the huge rush of blood donors, he forgot to
immediately remove the needle post collection, which led to a high-
volume collection [HVC] in the bag”. Additionally, it was found
that the total collection time was six minutes from the start of
phlebotomy. We also ruled out any inadvertent puncture of the
artery [there were no signs of pain, hematoma or extravasation of
blood as asked from the donor telephonically]. On further inquiry,
it was ascertained that a total volume of 435 ml WB was collected
in a 350-ml double CPDA-1 bag (Terumo Penpol Pvt Ltd, Trivan-
drum, India) on a kitchen scale instead of a blood collection monitor
[BCM]. Usually, BCMs tend to analyze the flow of the blood through
the tubing every 30 seconds during the collection phase, so that
an optimal flow may be ascertained [1]. This, however, was not
possible in this particular case since BCM was not utilized while
collecting the WB at the camp [while at the campsites, BCMs are
not taken usually]. In addition to the HVC [mismatch of the ratio
of the total WB volume collected (435 ml) and the anticoagulant
(49 ml)], the fact that the initial 90-cm length of the tubing attached
to the blood bag does not have any anticoagulant coating also
might have contributed to the activation of coagulation. The clot,
therefore, could have formed throughout this “non-coagulated”

https://doi.org/10.1016/j.tracli.2021.04.005
1246-7820/© 2021 Société française de transfusion sanguine (SFTS). Published by Elsevier Masson SAS. All rights reserved.
M. Raturi et al.
Fig. 1. The donor’s blood type was B Rh (D) positive (a). Moderately elongated threadlike clot in the PRBC unit (b) A magnified view of the same clot in the respective unit.
length of the tube, resulting in the threadlike appearance in the
bag [Figure 1]. The microbiological culture of the unit was sent
and found to be sterile. On doing a literature search, we found
that Shastry et al. had depicted various contributing factors which
influenced the formation of blood clots in their low-volume col-
lection [LVC-about 88 ml WB] unit.[2] Another study done by De
Korte et al. has suggested that manual mixing, by kneading the
blood bag at least three times a minute, may give at all the blood
flow rates, an almost ideal mixing curve.[3] Also, as per the Amer-
ican Association of Blood Banks (AABB) guidelines, it is advisable
not to harvest the platelet and plasma components, if the collec-
tion time [in min] exceeds by more than 10 and 15 respectively.
Further, AABB clearly mentions that the LVC units must be rela-
beled as “RBC’s low volume” while, their plasma and or platelet
components should not be harvested at all. On the contrary, HVC
[more than the upper limit of 10% collection beyond the speci-
fied amount] units must be straight away discarded as a WB unit
according to the recommendations [4]. Certainly, this fact was com-
pletely missed by us, since our component laboratory technician
had prepared both the components, namely, the PRBC as well as
the plasma from this HVC-WB (CPDA-1; double bag) unit. Follow-
ing this RCA, as a corrective action, we have now included the
volume-based recommendations and updated our SOP likewise.
We have also specifically instructed the technical staff to check
the proportionate volume of WB collected [in compliance with the
guidelines] rather, knead the blood bag (at least three times per
minute) using a kitchen scale at the campsite. Additionally, we
have emphasized the importance of adherence to the SOP to all
our technical staff while collecting whole blood and preparing the
components.
304
Transfusion Clinique et Biologique 28 (2021) 303–305
Informed consent
Not required.
Ethical Approval
All procedures performed in studies involving human par-
ticipants were in accordance with the ethical standards of the
institutional ethics committee and with the 1964 Helsinki decla-
ration and its later amendments or comparable ethical standards.
Financial support and sponsorship
Nil.
Contribution of authors
Mansi Kala and Ayushi Kediya contributed to the literature
search, data compilation, manuscript preparation, editing and
review, while Adityaveer Sahrawat contributed to the image acqui-
sition and the manuscript review. Manish Raturi contributed to
the conceptual design, literature search, manuscript preparation,
editing, review as well as being the guarantor who takes complete
responsibility for the integrity of the work done as the whole, right
from its inception to the published article.
Disclosure of interest
The authors declare that they have no competing interest.
M. Raturi et al. Transfusion Clinique et Biologique 28 (2021) 303–305

References [3] de Korte D, Veldman HA. Automated blood-mixing devices still fail to mix at low
bleeding rates. Vox Sang 2001;80:34–9.
[1] Limited TP. Monitor D 601. Chennai: India; Specification Blood Collection. [4] Dumont LJ, Papari M, Aronson CA, Dumont DF. Whole Blood Collection and Com-
http://www.bio-service.com.co/index htm files/D601.pdf [Last accessed on 20- ponent Processing. In: Fung MK, editor. Technical Manual. 18th ed Bethesda:
02-21]. American Association of Blood Banks; 2014. p. 135–66.
[2] Shastry S, Das S. Root-cause analysis for clot in blood bag. Asian J Transfus Sci
2016;10:3–4.

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