A colleague at a hospital in Missouri reports that when transfusing a patient with non-leukocyte reduced RBC units through their usual 180 micron filter blood administration set, the flow of two different RBC units was interrupted when the blood administration filters clogged, the first after 50 mL of red cells, and the second at the very end of the red cell transfusion. Their investigation did not reveal any obvious clots in either RBC unit, nor any unusual transfusion event such as the injection of a pharmaceutical into either unit. There was no delay in starting or stopping either transfusion and neither transfusion was interrupted (except for the clogging event). Furthermore, no TKO fluid was used, other than normal saline. The patient does not have a hyperviscosity syndrome. The inquiring colleague reports that during his 29 years of transfusion practice he has never seen two different RBC units clog up the blood administration set filters on the same day. He wants to know if anyone has advice, or has experienced similar problems?

The following comments have been submitted.

ADDENDA April 5, 2007

1. The colleague who originally submitted this discussion question reports that as of this morning (April 5, 2007) they now have documented a total of 4 clogged blood administration set filters, all using the same brand of filter, but involving three different lot numbers. The first three clogged blood administration set filters were infusing three different RBC units into the same patient, but the fourth clogged set was being used for a different patient, suggesting that this problem is not patient specific. The inquiring colleague reports that they have used the same brand of blood administration set filters exclusively since 2001, without previous problems, and use about 6,000 annually for red cells. So he is not convinced this problem is caused by the filters, but they do seem to be a common factor. Two different infusion pumps were used, and he has sent them both to their Biomedical Department for evaluation. The blood administration set manufacturer contacted the inquiring colleague today, and reportedly has had no reports of similar problems from other institutions. They did ask for the clogged filters to be sent to them for analysis, along with an unused sample of each of the three lot numbers, and a photo. Fortunately, there does not appear to be detectable harm to either patient.

ADDENDA Apr. 14, 2007

2. A colleague in Virginia wonders if the same transfusionist is the common denominator and if the sets were primed properly before transfusion.

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