December 2020 — Transfusion Medicine

A 45-year-old woman was feeling well and healthy, and she donated a unit of whole blood at a blood drive. She completed donation without difficulty, and her unit was sent for processing.

The donor's whole blood following centrifugation is shown in Figure 1, with the red cells on the bottom of the collection bag and the plasma portion at the top. Figure 2 shows the separated plasma from this patient (left) with a more typical bag of plasma for comparison (right).

Figure 1
Figure 2 -Donor plasma versus normal

Which of the following is most likely cause of the abnormal appearance of the plasma?

  • Bacterial contamination
  • Oral contraceptive effect
  • Hyperbilirubinemia
  • Lipemia

The correct answer is...

The correct answer is Lipemia.

Further review showed that this donor has a documented history of familial hypertriglyceridemia and hypercholesterolemia. Her triglyceride level measured approximately seven months prior was 5000 mg/dL (normal is considered <500). The plasma portion of this donation does not meet criteria for product acceptability; however, it serves as an illustrative example of this disease process. The lipemia did not interfere with infectious disease screening, and the red cell portion of the donation meets acceptability criteria for transfusion.

Oral contraceptive effect is known to cause light green discoloration of donor plasma. This is due to elevated levels of ceruloplasmin (a blue pigment) which blends with the natural yellow pigments present in plasma (such as transferrin, bilirubin, and carotenoids). Ceruloplasmin can be elevated by high estrogen states (OCP use and pregnancy) as well as by increased copper levels (which can seen in rheumatoid arthritis). Such plasma is recognized as a normal color variant by many blood banks; however, it can cause concern in the personnel administering the unit. Bacterial contamination, specifically with Pseudomonas species, can also result in a green discoloration of plasma; however, this is exceedingly uncommon with modern donor screening, aseptic processing, and additional inspection criteria (such as inspection for gas bubbles, clots, and opacity). This green discoloration is of a different hue than that seen in elevated ceruloplasmin states. Obviously, blood products with bacterial contamination are not acceptable for transfusion.

Hyperbilirubinemia results in icteric plasma, which can range from bright yellow to greenish brown. Causes can range from gallstones to congenital hepatic or metabolic disorders. A donor who presented with new-onset painless jaundice would hopefully be redirected towards additional workup. Icteric plasma is considered acceptable for transfusion, as long as the level of icterus does not interfere with the assay method used for required product and donor testing.

1. Sood, Tanvi, Ravneet Kaur Bedi, and Kshitija Mittal. "Discolored blood and blood components: A dilemma for transfusion specialists." Transfusion and Apheresis Science 50.2 (2014): 255-259.
2. Elkassabany, Nabil M., et al. "Green plasma—revisited." Anesthesiology: The Journal of the American Society of Anesthesiologists 108.4 (2008): 764-765.
3. Jenkins, C., et al. "Canadian Blood Services Visual Assessment Guide: A Tool to Promote Standardized Visual Assessment of Blood Components AP47." Transfusion 48 (2008). .

Photo of Daniel (Dan) Summerfield, M.D., M.S.. Daniel (Dan) Summerfield, M.D., M.S.
Resident, Transfusion Medicine
Mayo Clinic
Photo of Camille van Buskirk, M.D. Camille van Buskirk, M.D.
Consultant, Transfusion Medicine
Mayo Clinic
Assistant Professor of Laboratory Medicine and Pathology
Mayo Clinic College of Medicine and Science
MCL Education (@mmledu)

MCL Education

This post was developed by our Education and Technical Publications Team.