The visual inspection of blood products is not just good practice, but a requirement according to regulatory agencies and accrediting organizations. Inspecting blood products is critical to ensure that the safest ones are used and is the blood bank’s first step in assessing the suitability of a product for transfusion. There are many conditions that can affect the safety, quality, purity and potency (SQuIPP) of a blood product.
Causes that may result in loss of product suitability may include contamination resulting from donor failure to disclose an illness or injury, poor phlebotomy skills, or product mishandling that results in a break of sterility conditions (e.g. damage to container). In addition, manufacturing may not meet standard requirements so that product manipulation may impact cellular integrity or leukoreduction filtration failures occur.
Visual inspection of the product should begin by ensuring that (1) all ports are sealed; (2) there is no sign of leakage; (3) labels are adhered to container; and (4) verification that the product has not expired.
The following information has been provided to assist in identifying any abnormalities. If the blood products do not meet standard visual inspection guidelines, quarantine the unit and follow the facility’s policy to determine suitability and/or receive approval to use from the blood bank’s Medical Director. If product is deemed unsuitable, notify the blood vendor.
Red blood cells (RBC) primary function is to carry oxygen to tissues throughout the body. Donor RBC units are transfused when the patient presents with anemia from causes such as blood loss or diseases that may impact RBC production in the bone marrow, as seen with infections or cancers +/- chemotherapy. Refer to the plasma section for a summary of observations regarding the RBC’s residual plasma supernatant. Use the integrally attached segments to compare to the product, which should be similar.
- Color: an RBC unit normally is red in color, ranging from bright cherry red to a deep burgundy, with the brighter color possibly representing an incidental arterial drawn collection or hemolysis, while a darker color might indicate a higher concentration of red cells.
- Lipemia may result in a lighter shade of red with opacity; this is also considered suitable for transfusion. Of concern is when the color turns darker, to a purple or even black hue, which may be a sign of contamination.
- Volume: if a unit is smaller than expected (< 300 ml) or there is not sufficient plasma supernatant, it is possible that there is insufficient additive solution.
- Clots: Clots may represent fibrin, cellular, cold agglutinins resulting in a unit which should not be transfused.
Plasma is the non-cellular portion of blood and can either be liquid or frozen. Plasma is used to treat factor deficiencies, bleeding, or coagulation problems.
- Color: pink to red indicates the presence of RBC contaminant. If this is the case, and the Rh status is unknown, the unit should not be transfused to a recipient who is expecting Rh negative blood products. White with opacity (lipemia), yellow to brown coloration (icterus), green (oral contraceptive) are considered suitable for transfusion. Gray to brown +/- opaque is a concern for contamination
- Volume: may be variable (200 – 600 ml), depending on the manufacturing process.
- Air bubbles: frothy small air bubbles are considered normal; however, excessive air bubbles and fibrin clots may be a sign of contamination.
Platelets are mostly used in the treatment for thrombocytopenia, platelet function abnormalities and may be used prophylactically in those patients at risk for bleeding. Refer to the prior plasma section for visual inspection guidance; in addition, clots or clumps present in the product are not part of its normal appearance and very likely indicate the potential for bacterial contamination.
Bacterial contamination is more likely to occur in platelet products since they are stored at room temperature rather than refrigerated or frozen.
Cryoprecipitated AHF (“cryo”) is used to correct coagulopathy in massive transfusion protocols, DIC, liver failure and conditions diagnosed as hypofibrinogenemia. The normal appearance for cryo is an off white, paste-like. This product should also not have any clumps, RBC contaminant, or excessive air bubbles present in its bag.
When performing visual inspection, for consideration is determining risk for bacterial contamination, the most common transfusion transmitted infection a recipient may encounter. Bacterial contamination is more likely to occur in platelet products as they are stored at room temperature rather than refrigerated or frozen. A contaminated product that goes unnoticed can cause a septic reaction which can lead to fever, rigors, hypotension, shock, tachycardia, dyspnea, nausea and vomiting. Care givers must be vigilant in noticing these signs and should stop the transfusion immediately, support the patient, notify the transfusion service, collect blood samples and alert the physician.
To prevent such transfusion associated complications, it is important to always inspect the received blood products. If any product is deemed unacceptable to transfuse, then the supplier should be notified as soon as possible so that they may take appropriate action. Such steps can include tracing and, if possible, interception before a co-component is transfused.
For this reason, visual inspection of blood products is the first step transfusion services are to take in ensuring the safest blood supply possible.
American Red Cross Resource:
- ARC SUCCESS education: Visual Inspection of Blood Products. Presented by Smith L, Smietana S, and Kezeor K. Available at successEducation@redcross.org
- ARC Blood Component Visual Inspection Guide (job aid):
- American Red Cross Biomedical Services, 21.4.ja024: Visual Inspection Reference Guide
- Fatalities reported to FDA Following Blood Collection and Transfusion. Annual Summary for Fiscal Year 2019. Washington, DC: Center for Biologics Evaluation and Research, Office of Compliance and Biologics Quality, Division of Inspections and Surveillance, 201. J Thomas, RN, BSN; J Parks, MD, FASCP; T Hannon. Under-recognition and Under-reporting of Transfusion-Related Adverse Events [abstract]. Transfusion. 2009;49:2249.
- Slapak C, Fredrich N, Wagner J. Transfusion Safety; is this the business of blood centers?. Transfusion 2011;51:2767-2771.
- Fung MK, Eder AF, Spitalnik SL, Westhoff CM, editors. Technical Manual. 19th edition.Bethesda (MD): AABB; 2017.
- Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Manual Biovigilance Component. Protocol v1.3.1. Atlanta (GA); 2019 Jun.
- Fridey JL, et al. A Compendium of Transfusion Practice Guidelines. 4th edition. American Red Cross; 2021
- Gregory KL, Biehl RB. Blood Bank Regulations: A-Z. 6th edition. Bethesda (MD): AABB press; 2005.
- American Association of Blood Banks, Standards for Blood Banks and Transfusion Services 31st edition,2018
- Smith L, Smietana S and Kezeor K. Visual Inspection of Blood Products. ARC SUCCESS presentation available at successEducation@redcross.org