Asian Journal of Transfusion Science
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CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 1  |  Page : 50-52

Snake in the grass: A case report of transfusion reactions due to contaminated donor arm disinfectant


1 Department of Transfusion Medicine, T. S. Misra Medical College and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Correspondence Address:
Anju Dubey
Department of Transfusion Medicine, T. S. Misra Medical College and Hospital, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6247.200775

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Bacterial contamination of blood components remains an on-going challenge. In the majority of cases, organisms contaminating the blood components are a part of normal skin flora. Here, we report a case of bacterial contamination of blood units through contaminated donor arm disinfectant. There was a series of reactions due to random donor platelet (RDP) transfusion. The patients had features of septic transfusion reactions. On root cause analysis, spirit swabs used for disinfection of donors' arm were identified as the culprit and presence of Clostridium difficile was established. All the blood components prepared on the dates of implicated RDP units were removed from the stock and we replaced the existing 70% alcohol disinfectant with chlorhexidine-alcohol-based antiseptic rub. Further, no such transfusion reactions were reported. Implementation of good donor arm disinfection technique in addition to the use of blood bags with diversion pouch is proposed to be best preventive strategy for resource-poor settings.


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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
Online since 10th November, 2006