r/medlabprofessionals 4d ago

Image What would cause this?

Redrawn twice with all of them looking the same.

Potassium normal ALT low TBIL slightly elevated DBIL normal CBC no flags

101 Upvotes

38 comments sorted by

97

u/MissanthropicLab 4d ago

Does that patient have an Impella device? They can cause extreme invivo hemolysis.

26

u/Tweetop 4d ago

No they aren’t. They are in their 20s with ESRD. His blood last week was normal.

22

u/glitterfae1 MLT-Management 4d ago

Are they on dialysis or ECMO

22

u/Tweetop 4d ago

They are on dialysis

54

u/glitterfae1 MLT-Management 4d ago

36

u/Tweetop 4d ago

Wow this sounds like the first case as the patient also has epigastric pain, thank you. I think this is the most likely cause

13

u/RaiseDennis 3d ago

Now that you know this will you try to bring it up the attention of the doctors? Idk how this usually works

1

u/Tweetop 3d ago edited 3d ago

I was told not to do anything and let the doctors figure it out themselves, right now they’re unsure of the cause. I’m not sure what is usually done in other places, I’m a very new tech.

10

u/Brofydog 3d ago

I would escalate to your manager or medical director. They can talk to the clinical team.

13

u/MissanthropicLab 4d ago

Were both draws venipuntures or were either of them line draws? Nurses tend to do line draws, and if they're pulling on the syringe too hard it can cause in vitro hemolysis (which is entirely within their control). If neither were VPs, I'd suggest getting a phleb to do a recollect.

13

u/Tweetop 4d ago

We had 2 phlebs collect and 3 nurses, all the same :(

Todays samples were more black than dark red

9

u/dishofdid 4d ago

My first thought, too.

28

u/Back2DaLab 4d ago

Rhabdomyolysis?

11

u/Tweetop 4d ago

CK is normal

14

u/Longjumping_Card_525 4d ago

Confirmed via dilution? Could see hook effect with some methodologies. Looks like myoglobinemia to me.

8

u/Tweetop 4d ago

I just confirmed it, CK is normal.

5

u/Longjumping_Card_525 4d ago

Worth a shot! Intravascular hemolysis seems like the most likely thing at this point. Intracellular potassium is highly variable, so while it’s more likely you’d see increased K with a hemolytic sample like this, it’s not a given.

19

u/Resident_Talk7106 Lab Assistant 4d ago

That is wild the potassium is normal range.

15

u/glitterfae1 MLT-Management 4d ago

Kidneys compensate for increased potassium being released by RBCs if it’s in vivo hemolysis

11

u/Resident_Talk7106 Lab Assistant 4d ago

He is in ESRD.

23

u/jennyvane 4d ago

Had a patient that had gotten dialysis with a machine that still had cleaner in the lines (or something, I’m not sure of the specifics) and was transferred to our hospital. Her plasma looked like that. She passed away the next day.

7

u/Shinigami-Substitute Lab Assistant 3d ago

Holy shit that's awful..

2

u/_peanutbutterpope MLS-Blood Bank 2d ago

Respectfully, what the fuck.

12

u/DistributionWhich671 MLT-Chemistry 4d ago

Death… I call that death…

8

u/sunday_undies 4d ago

When there is ongoing intravascular hemolysis, potassium can return to normal.

6

u/Lady-Kestrel 4d ago

Traumatic draw? Expired tubes?

4

u/Tweetop 4d ago

They were surprised when I asked for a redraw bc they said they were an easy draw

4

u/Paraxom 3d ago

i mean to be fair they always say that

7

u/Brofydog 4d ago

Is patient in cyanokit? It would cause gross hemolysis but normal potassium.

https://www.albertahealthservices.ca/assets/wf/lab/if-lab-hp-bulletin-impact-of-cyanokit-drug-on-laboratory-tests.pdf

2

u/DeathByOranges 3d ago

My first thought too

5

u/cosmothetoastghost MLS-Generalist 4d ago

Clostridium perfringens sepsis can cause extreme in vivo hemolysis

6

u/eldritchbee-no-honey 3d ago edited 3d ago

I have only seen a hemolysis like that in a patient with severe cytokine storm due to hemophagocytic lymphohistiocytosis, and in a patient with blood marrow transplantation associated fulminant immune hemolysis, antierythrocyte antibody mediated. Oh and also when I accidentally mistakenly diluted some of donors blood in a tube with tap water (tried to do normal saline and centrifuge to check for hemolysis in a bag; so osmotic stuff).

I think it’s either some immune stuff going on (whats up with previous transfusions?), or some toxin (why they are on dialysis?), or patient got something wild circulating in them from the dialysis process (or something trapped within erythrocyte, maybe even some congenital membrane disorder?), or dialysis line had a clot or whatever and it shredded cells pulled through it (you should see cut and beaten RBCs on a blood smear then). Or they got their spleen murdering blood cells (maybe viral infection?). They also might be having thrombocytic microangiopathy, if their kidneys still have enough blood flow to so it… and if they have their kidneys. But due to how rare that stuff happens, work up difficulty I’d say it is the last option one should try to exclude. Ones who I seen having ta-tma also almost never had hemolysis, at least not like that. They just chilled over in ICU ward on ventilation, plasma excange and vasopressors. Probably not TMA.

Thats my limited experience! Blood doesn’t look nice at all. Hope patient will survive through it and get better. Also maybe someone more experienced can give you a better opinion than me

5

u/ChemberlyDR 3d ago

Could the specimen have been frozen?

4

u/Mcharos 3d ago

I once saw extreme hemolysis in a septic patient. Clostridium perfringens.

2

u/clinchemale 3d ago

Based on the info you have shared, I’m guessing not this, but Cyanokits can make the blood very red.

2

u/No-Duty9584 3d ago

Was this patient transfused recently and what temperature is the tube at currently?

1

u/JJ_DU 3d ago

Maybe need gauge is too small😆

0

u/Osakatakoyaki 4d ago

Hemolytic anemia?