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Is there a risk of misinterpretation of potassium concentration from undetectable hemolysis using a POCT blood gas analyzer in the emergency department?

Open access
Nigro, Marianna, Valli, Gabriele, Marchionne, Maria Luisa, Sattarinia, Dario, Silvestrini, Fabiana, De Pietro, Daniele, Fazzini, Simone, Roselli, Giorgia +10 more·2022·Medicina
DOI 10.3390/medicina59010066PMC PMC9861078
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Abstract

Background and Objectives: Hemolysis is reported to be present in up to 10% of blood gas specimens in the central lab; however, few data on the incidence of hemolysis using a point-of-care testing (POCT) blood gas analysis are available in the setting of the emergency department. The aims of this study were: (1) to analyze the prevalence of hemolysis in blood gas samples collected in the ED using a POCT device; and (2) to evaluate the impact of hemolysis on blood sample results and its clinical consequences. Materials and Methods: We collected 525 consecutive POCT arterial blood gas samples using syringes with electrolyte-balanced heparin within 3 different EDs in the metropolitan area of Rome. Immediately after the collection, the blood samples were checked for the presence of hemolysis with a POCT instrument (i.e., HEMCHECK, H-10 ®). The samples were then subsequently processed for blood gasses, and an electrolytes analysis by a second operator blinded for the hemolysis results. A venous blood sample was simultaneously collected, analyzed for it’s potassium value, and used as a reference. Results: Of the samples, 472 were considered for the statistics, while 53 were excluded due to the high percentage of hemolysis due to operator fault in carrying out the measurement. The final mean hemolysis per operator was 12% (±13% SD), and the total final hemolysis was 14.4%.Potassium (K+) was significantly higher in the hemolyzed group compared with the non-hemolyzed sample (4.60 ± 0.11 vs. 3.99 ± 0.03 mEq/L; p < 0.001), and there were differences between arterial potassium versus venous potassium (D(a-v) K+, 0.29 ± 0.06 vs.−0.19 ± 0.02 mEq/L, p < 0.01). A Bland–Altman analysis confirmed that hemolysis significantly overestimated blood potassium level. Conclusion: Almost 12% of POCT blood gas analysis samples performed in the ED could be hemolyzed, and the presence of this hemolysis is not routinely detected. This could cause an error in the interpretation of the results, leading to the consideration of potassium concentrations being below the lower limit within the normal limits and also leading to the diagnosis of false hyperkalemia, which would have potential clinical consequences in therapeutic decision-making in the ED. The routine use of a POCT hemolysis detector could help prevent any misdiagnoses.

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  • Multiple factors contribute to discrepancies between POCT and laboratory values: variation in sample matrix, pre-analytical handling, device calibration intervals, and analytical methodology.

    “Multiple factors contribute to discrepancies between POCT and laboratory values: variation in sample matrix (whole blood vs. serum/plasma), pre-analytical handling, device calibration intervals, and analytical methodology [4,5].”

    From Reliability of Point-of-Care Venous Blood Gas Testing for Potassium and Sodium Compared to Central Laboratory Results in Emergency Patients: A Clinical Audit (2025) · cites this paper as [5]

    The Introduction and Discussion support pre-analytical handling as a source of error: collection, transport, storage, and hemolysis can alter measured potassium. The Introduction also notes that central laboratories routinely check for hemolysis whereas blood-gas POCT systems do not. Our copy does not identify sample-matrix variation or device calibration intervals as causes of POCT–laboratory discrepancies, or establish analytical methodology more generally as a cause. (LLM, conf=0.87)

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  • Hemolysis, often undetectable during POCT, and sampling inconsistencies can result in elevated potassium readings.

    “These discrepancies are also aligned with findings from Nigro et al. [5], who reported that hemolysis, often undetectable during POCT, and sampling inconsistencies can result in elevated K⁺ readings, potentially triggering unnecessary interventions.”

    From Reliability of Point-of-Care Venous Blood Gas Testing for Potassium and Sodium Compared to Central Laboratory Results in Emergency Patients: A Clinical Audit (2025) · cites this paper as Nigro et al. [5]

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Authors
Nigro, M., Valli, G., Marchionne, M. L., Sattarinia, D., Silvestrini, F., De Pietro, D., Fazzini, S., Roselli, G., Spallino, A., Praticò, V., Mirante, E., Castaldo, E., Pugliese, F. R., Cicchini, C., Ancona, C., De Marco, F., Ruggieri, M. P., & Di Somma, S.
Affiliations
  • Sapienza University of Rome (IT)
  • Azienda Ospedaliera San Giovanni Addolorata (IT)
  • Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
  • St. Eugenio Hospital (IT)
  • Ospedale Sandro Pertini (IT)
  • Emergency Department, San Giovanni Addolorata Hospital, 00184 Rome, Italy
ORCID
Venue
Medicina
Publisher
MDPI AG
Published
2022-12-28
Volume
59
Issue
1
Pages
66
ISSN
  • 1010-660X (ISSN-L)
  • 1648-9144
DOI
10.3390/medicina59010066
PMC
PMC9861078
OpenAlex
W4313413103
Cited by
16
References
25
Citations by year
2026: 2 · 2025: 7 · 2024: 4 · 2023: 3
FWCI
2.17
Type
journal article
Language
en
Open access
Licence
Locations
  • Medicina (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Topics
  • Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Potassium and Related Disorders
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Clinical Biochemistry › Bacterial Identification and Susceptibility Testing
Keywords
hemolysis, point-of-care testing, blood gas analysis, potassium measurement, arterial blood gases, emergency department, hemolysis detection, laboratory errors, sample quality control, Bland-Altman agreement, intensive care
MeSH terms
Point-of-Care Testing, Blood Gas Analysis, Emergency Service, Hospital, Hemolysis, Humans, Potassium

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