title: Infusion pump-mediated mechanical hemolysis in pediatric patients.
abstract: BACKGROUND
  Hemoglobinuria was observed after packed red blood cell transfusion in a series of patients at our pediatric treatment center. Laboratory testing was suggestive of intravascular hemolysis with no support for an immunohematologic process.
  
  
  OBJECTIVE
  We investigated these adverse events to define a quality improvement plan and to prevent future hemolytic adverse events. Multiple factors were investigated, and the only change identified was the implementation of a new infusion pump (Pump A) that replaced a previous model (Pump B).
  
  
  METHODS
  In vitro pump analyses, a retrospective review of urinalyses, and prospective urinalysis and nursing surveillances were also performed.
  
  
  RESULTS
  In in vitro analysis of the pumps, irradiated units with higher hematocrit at a low flow rate through Pump A had a greater than thirty-fold increase in free hemoglobin from baseline compared to minimal free hemoglobin changes seen with Pump B. Irradiated units with a lower hematocrit had a minimal change in free hemoglobin from baseline with both Pumps A and B at either low or high flow rate. Subsequently, only units with lower hematocrits were issued for transfusion of pediatric patients, and Pump A was replaced by Pump B in the outpatient unit. Retrospective and prospective surveillances found no additional unexplained cases of gross hemoglobinuria associated with transfusion.
  
  
  CONCLUSIONS
  The investigation determined that infusion of higher hematocrit units using a specific commercial pump was associated with mechanical hemolysis. The change to units with lower hematocrit through an alternative pump has been an effective corrective action to date.
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Hughes
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA.
authors.forename: Janet
authors.initials: J
authors.lastname: McNaughton
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Andrews
authors.affiliation: Department of Pathology, University of New Mexico, Albuquerque, NM.
authors.forename: Tracy
authors.initials: T
authors.lastname: George
authors.affiliation: Center for Nursing Excellence, Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital (LPCH), Palo Alto, CA.
authors.forename: Cassandra
authors.initials: C
authors.lastname: Bergero
authors.affiliation: Center for Nursing Excellence, Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital (LPCH), Palo Alto, CA.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Pyke-Grimm
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Galel
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Gonzalez
authors.affiliation: Department of Pathology, Stanford University, Stanford, CA Medicine, Stanford University, Stanford, CA.
authors.forename: Lawrence Tim
authors.initials: LT
authors.lastname: Goodnough
authors.affiliation: Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA magalifontaine7@gmail.com.
authors.forename: Magali J
authors.initials: MJ
authors.lastname: Fontaine
mesh_terms: D001803:Blood Transfusion; D002648:Child; D002675:Child, Preschool; D005260:Female; D006454:Hemoglobins / Q000378:metabolism; D006461:Hemolysis; D006801:Humans; D007260:Infusion Pumps; D008297:Male
chemical_list: D006454:Hemoglobins
keywords: corrective action; infusion pump; mechanical hemolysis; quality improvement