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Case Reports
. 2017 Jan-Jun;11(1):50-52.
doi: 10.4103/0973-6247.200775.

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

Anju Dubey  1 , Atul Sonker  2 , Rajendra Chaudhary  2
Affiliations
Case Reports

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

Anju Dubey et al. Asian J Transfus Sci. 2017 Jan-Jun.

Abstract

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.

Keywords: Bacterial contamination; donor arm disinfectant; random donor platelets.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Ishikawa (Fishbone) diagram for identifying potential source of bacterial contamination of blood components.
See this image and copyright information in PMC

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