Blood-fluid warmers are commonly used in clinical practice, particularly in the emergency service and the operating rooms, for transfusing blood, blood products, and fluids by preventing the adverse effects of hypothermia. Line-type blood-fluid warmers are the most commonly used types since they are highly practical, inexpensive, and also do not require an additional kit for administration. [1][2][3] In Turkey, most medical devices such as blood infusion sets and blood bags are made of polyvinylchloride (PVC) that contain di-(2-ethylhexyl) phthalate (DEHP) as a plasticizer C.It is commonly known that DEHP leaches from the bag into the blood and blood products as a result of warming. 4,5 Moreover, DEHP converts to a more toxic metabolite known as mono (2-ethylhexyl) phthalate (MEHP) during the heating process. [4][5][6] It has been previously shown that exposure to DEHP-containing substances through inhalation or skin contact may result in gonadal injury or toxic effects on the reproductive system and kidneys. 2 It has also been recently reported that there is an association between exposure to DEHP and atopic dermatitis. 7 However, various harms of phthalate exposure have also been reported in human studies. [8][9][10]

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It is commonly known that stored blood and blood products are heated before transfusion in order to prevent hypothermia, which leads to increased di-(2-ethylhexyl) phthalate content leaching into the blood and blood products and thereby causes greater conversion of di-(2-ethylhexyl) phthalate to mono (2-ethylhexyl) phthalate. However, there has been no study in the literature reporting on the amount of toxic phthalates in blood following the erythrocyte suspension transfused via warming. In this study, we aimed to investigate the di-(2-ethylhexyl) phthalate and mono (2-ethylhexyl) phthalate content in blood following the ES transfusions administered by di-(2-ethylhexyl) phthalate -containing and di-(2-ethylhexyl) phthalate -free infusion sets. The study included 30 patients that were randomly divided into 2 groups with 15 patients each: group I underwent erythrocyte suspension transfusion via di-(2-ethylhexyl) phthalate -containing infusion sets warmed with blood-fluid warmers and group II underwent erythrocyte suspension transfusion via di-(2-ethylhexyl) phthalate-free infusion sets warmed with blood-fluid warmers. Di-(2-ethylhexyl) phthalate and mono (2-ethylhexyl) phthalate levels were measured both before and after transfusion. Di-(2-ethylhexyl) phthalate-free infusion sets led to no increase in the phthalate content, whereas di-(2-ethylhexyl) phthalate-containing infusion sets significantly increased the di-(2-ethylhexyl) phthalate and mono (2-ethylhexyl) phthalate levels, where the di-(2-ethylhexyl) phthalate level increased almost four times (p=0.001). Di-(2-ethylhexyl) phthalate-containing products lead to toxicity. Therefore, using di-(2-ethylhexyl) phthalate-free products may prevent toxicity in patients undergoing erythrocyte suspension transfusion.

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