Sir,
A 29-year-old male patient with carcinoma of the gastroesophageal junction was posted for transhiatal esophagectomy. Intraoperatively, 2 units of packed red cells were ordered for transfusion to the patient and were issued to the patient as per the departmental standard operating procedure including pretransfusion testing and mandatory visual inspection. During transfusion in the operation theater, anesthesiologists noticed a distinct blue hue in the tubings of the blood administration set [Figure 1]. Immediately transfusion was stopped and noticing that the color of the blood bag being normal, a different blood administration set was connected and transfusion was restarted. The blue color reappeared in the administration set. The transfusion was stopped and the blood bag along with the transfusion set was received by the transfusion department. The blood bag had no discoloration. The tubing of the administration set carrying blood had bluish discoloration which intensified under artificial source of light. The blood that was allowed to flow through the administration set was collected in a clean test tube and was noticed not to have any discoloration or hemolysis. The administration set was flushed with normal saline repeatedly and was then compared with another unused new administration set. This particular administration set (manufactured by P. H. Medisurge, Ahmedabad, Gujarat, India) had a bluish tinge [Figure 2]. The problem was noticed only with the particular batch (lot no ABT-07) of administration set and did not recur after changing the batch.
Figure 1.
Blood in the infusion set with a blood bag tube for comparison
Figure 2.
Completely flushed blood administration setthe
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