A colleague who works at a blood center in the midwest that has been providing 100% Leukocyte Reduced RBCs for about 3 years reports that their largest hospital customer is experiencing problems with some units of RBCs 'breaking' when the units are transported to the various floors via a pneumatic tube system. The hospital has transported RBCs via a pneumatic tube system for over 10 years, but it is only in the last year or so that the hospital reports experiencing greater than usual breakage when using the pneumatic tube. One curious factor reported by the inquiring colleague is that most leaks appear to be coming from a single small (approx. 5mm) slit in the bag under the base label. There is no evidence of tearing or slit in the base label itself, and no evidence of tearing in the overwrap (baggie). The inquiring colleague asks if anyone else has experienced a similar problem, and if so, has a cause and corrective action for the leakage been determined.

ADDENDA Nov. 25, 2003

The following responses have been received.

1. A colleague in Texas reports that they have experienced problems with leakage of FFP and an occasional leukocyte-reduced RBC unit. Interestingly, the Texan reports that the leakage is not limited to units sent via the pneumatic tube. The location of the leak appeared to be a slit under the label, similar to that reported by the colleague from the midwest. The Texan could not find a tear of any kind in the label and had to carefully remove the label to find the exact source of the leak. Their FFP and RBC units leaked in the same spot, just under the blood type label, toward the bottom of the label. They found the leaks by observing blood/FFP seeping out around the labels.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator