Can J Anesth/J Can Anesth (2014) 61:209–210 DOI 10.1007/s12630-013-0078-5
CORRESPONDENCE
The colour of plasma F. Louis Kirk III, MD • Anshu Bandhlish, MBBS • Vivek Arora, MBBS, MD • Charles H. Brown IV, MD
Received: 30 July 2013 / Accepted: 4 November 2013 / Published online: 20 November 2013 Ó Canadian Anesthesiologists’ Society 2013
To the Editor, During a repeat single-lung transplant, severe coagulopathy with hemorrhage developed in a patient who then went on to require massive transfusion of blood and blood products. Three units of fresh frozen plasma (FFP) that were sent from the blood bank had strikingly different colours (Figure). We queried anesthesiology and surgical team members in the operating room, and all were unaware of the etiology and therefore the suitability to transfuse one of these units (Bag No. 3: green discolouration). Subsequently, this bag was returned to the blood bank. On follow-up, we realized that it was safe to administer this green discoloured unit of FFP to patients. We not only identified a knowledge gap in health care providers routinely dealing with blood and blood product transfusion, but also recognized that valuable blood bank and operating room resources were diverted to deal with the issue. It is essential that anesthesiologists recognize normal and abnormal variations in the appearance of FFP. Accordingly, we present a brief review of the wide-ranging appearances of FFP encountered in daily practice. The typical yellow colour of FFP (Bag 1) is imparted by bilirubin, carotenoids, hemoglobin, and transferrin. Suspended lipid particles containing triglycerides can result in a turbid milky appearance (Bag 2). This is
F. L. Kirk III, MD V. Arora, MBBS, MD C. H. Brown IV, MD (&) Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] A. Bandhlish, MBBS Department of Pathology and Laboratory Medicine, Georgetown University Hospital, Washington DC, USA
attributed to donor lipemia seen after a fatty meal prior to donation or donor hypertriglyceridemia. These units are safe to administer to patients unless the triglyceride concentration exceeds 3,000 mgdL-1, which can interfere with diagnostic assays for infectious diseases.1 Green discolouration (Bag 3) results from increased ceruloplasmin levels, which occurs in high estrogen states, including pregnancy or use of oral contraceptives. Green discolouration can also be due to contamination of plasma units by gram negative cryophilic organisms, but this rarely occurs in the current era of widespread use of antibiotics.2 Salmon-tinged or redcoloured FFP (Bag 4) is caused by incomplete separation of erythrocytes during production of FFP from whole blood. Fresh frozen plasma with each of these appearances, i.e., milky-white, green, or red coloured, are safe to transfuse.3 Several other appearances of FFP not shown in our image may be seen in clinical practice. First, a deep yellow discolouration is associated with donor icterus. With the current highly sensitive assays used to screen donors for infectious agents, this can be safely attributed to noninfectious inherited liver disorders, e.g., Gilbert syndrome and cholelithiasis, and such units are safe for patient administration.3,4 Second, orange discolouration may occur due to the presence of vitamin A or large quantities of b-carotenoids. Similar to red, yellow, and green discoloured units, these are safe for patient transfusion.3 Third, bacterial contamination can occasionally result in unusual air bubbles and activation of clotting system resulting in clots, fibrin strands, and increased opacity. These units should not be administered and should be returned to the blood bank.3 Fourth, white or opaque particulate matter that does not dissipate with gentle agitation may be seen occasionally. This particulate matter is generally composed of platelets, white or red blood cells, and fibrin. Fresh frozen plasma containing such cellular and
123
210
F. L. Kirk III et al.
plasma. We encourage consultation with blood bank personnel or referral to print and online resources available from national blood banks (such as the Canadian Blood Services Visual Assessment Guide)3 when dealing with such situations. Conflicts of interest
None declared.
Funding This work was supported by National Institutes of Health (NIH) KL-2 Clinical Research Scholars Program, NIH (RO3 AG042331), and the Jahnigen Career Development Award (C.B.).
Figure Normal variations in the colour of fresh frozen plasma (FFP): 1. Yellow FFP; 2. Milk-turbid FFP; 3. Green FFP; 4. Salmoncoloured FFP
fibrin aggregates are not safe for transfusion and should be returned to the blood bank.3 Contemporary health care places an ever-greater emphasis on efficient utilization of health care resources. Blood products are a limited resource that anesthesiologists rely on frequently when caring for surgical patients. In order to ensure patient safety and efficient utilization of health care resources, it is essential that anesthesiologists be familiar with the normal and abnormal appearance of
123
References 1. Peffer K, de Kort WL, Slot E, Doggen CJ. Turbid plasma donations in whole blood donors: fat chance? Transfusion 2011; 51: 1179-87. 2. Elkassabany NM, Meny GM, Doria RR, Marcucci C. Green plasma-revisited. Anesthesiology 2008; 108: 764-5. 3. Canadian Blood Services. Visual Assessment Guide T05 021 (January 2009). Available from URL: http://www.transfusion medicine.ca/resources/visual-assessment-guide (accessed October 2013). 4. Naiman JL, Sugasawara EJ, Benkosky SL, Mailhot EA. Icteric plasma suggests Gilbert’s syndrome in the blood donor. Transfusion 1996; 36: 974-8.
CORRESPONDENCE
The colour of plasma F. Louis Kirk III, MD • Anshu Bandhlish, MBBS • Vivek Arora, MBBS, MD • Charles H. Brown IV, MD
Received: 30 July 2013 / Accepted: 4 November 2013 / Published online: 20 November 2013 Ó Canadian Anesthesiologists’ Society 2013
To the Editor, During a repeat single-lung transplant, severe coagulopathy with hemorrhage developed in a patient who then went on to require massive transfusion of blood and blood products. Three units of fresh frozen plasma (FFP) that were sent from the blood bank had strikingly different colours (Figure). We queried anesthesiology and surgical team members in the operating room, and all were unaware of the etiology and therefore the suitability to transfuse one of these units (Bag No. 3: green discolouration). Subsequently, this bag was returned to the blood bank. On follow-up, we realized that it was safe to administer this green discoloured unit of FFP to patients. We not only identified a knowledge gap in health care providers routinely dealing with blood and blood product transfusion, but also recognized that valuable blood bank and operating room resources were diverted to deal with the issue. It is essential that anesthesiologists recognize normal and abnormal variations in the appearance of FFP. Accordingly, we present a brief review of the wide-ranging appearances of FFP encountered in daily practice. The typical yellow colour of FFP (Bag 1) is imparted by bilirubin, carotenoids, hemoglobin, and transferrin. Suspended lipid particles containing triglycerides can result in a turbid milky appearance (Bag 2). This is
F. L. Kirk III, MD V. Arora, MBBS, MD C. H. Brown IV, MD (&) Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] A. Bandhlish, MBBS Department of Pathology and Laboratory Medicine, Georgetown University Hospital, Washington DC, USA
attributed to donor lipemia seen after a fatty meal prior to donation or donor hypertriglyceridemia. These units are safe to administer to patients unless the triglyceride concentration exceeds 3,000 mgdL-1, which can interfere with diagnostic assays for infectious diseases.1 Green discolouration (Bag 3) results from increased ceruloplasmin levels, which occurs in high estrogen states, including pregnancy or use of oral contraceptives. Green discolouration can also be due to contamination of plasma units by gram negative cryophilic organisms, but this rarely occurs in the current era of widespread use of antibiotics.2 Salmon-tinged or redcoloured FFP (Bag 4) is caused by incomplete separation of erythrocytes during production of FFP from whole blood. Fresh frozen plasma with each of these appearances, i.e., milky-white, green, or red coloured, are safe to transfuse.3 Several other appearances of FFP not shown in our image may be seen in clinical practice. First, a deep yellow discolouration is associated with donor icterus. With the current highly sensitive assays used to screen donors for infectious agents, this can be safely attributed to noninfectious inherited liver disorders, e.g., Gilbert syndrome and cholelithiasis, and such units are safe for patient administration.3,4 Second, orange discolouration may occur due to the presence of vitamin A or large quantities of b-carotenoids. Similar to red, yellow, and green discoloured units, these are safe for patient transfusion.3 Third, bacterial contamination can occasionally result in unusual air bubbles and activation of clotting system resulting in clots, fibrin strands, and increased opacity. These units should not be administered and should be returned to the blood bank.3 Fourth, white or opaque particulate matter that does not dissipate with gentle agitation may be seen occasionally. This particulate matter is generally composed of platelets, white or red blood cells, and fibrin. Fresh frozen plasma containing such cellular and
123
210
F. L. Kirk III et al.
plasma. We encourage consultation with blood bank personnel or referral to print and online resources available from national blood banks (such as the Canadian Blood Services Visual Assessment Guide)3 when dealing with such situations. Conflicts of interest
None declared.
Funding This work was supported by National Institutes of Health (NIH) KL-2 Clinical Research Scholars Program, NIH (RO3 AG042331), and the Jahnigen Career Development Award (C.B.).
Figure Normal variations in the colour of fresh frozen plasma (FFP): 1. Yellow FFP; 2. Milk-turbid FFP; 3. Green FFP; 4. Salmoncoloured FFP
fibrin aggregates are not safe for transfusion and should be returned to the blood bank.3 Contemporary health care places an ever-greater emphasis on efficient utilization of health care resources. Blood products are a limited resource that anesthesiologists rely on frequently when caring for surgical patients. In order to ensure patient safety and efficient utilization of health care resources, it is essential that anesthesiologists be familiar with the normal and abnormal appearance of
123
References 1. Peffer K, de Kort WL, Slot E, Doggen CJ. Turbid plasma donations in whole blood donors: fat chance? Transfusion 2011; 51: 1179-87. 2. Elkassabany NM, Meny GM, Doria RR, Marcucci C. Green plasma-revisited. Anesthesiology 2008; 108: 764-5. 3. Canadian Blood Services. Visual Assessment Guide T05 021 (January 2009). Available from URL: http://www.transfusion medicine.ca/resources/visual-assessment-guide (accessed October 2013). 4. Naiman JL, Sugasawara EJ, Benkosky SL, Mailhot EA. Icteric plasma suggests Gilbert’s syndrome in the blood donor. Transfusion 1996; 36: 974-8.
