Urgent Requirement for RBCs

[goodchild]

We're reviewing our procedure for the provision of blood products before completion of pretransfusion/compatibility testing. Our medical staff has also asked for an educational tool that can be used house-wide. I'm very curious of the generally accepted practice standards of the BBT community.

 

One major focus is on how everyone handles a situation where an antibody screen is positive (or a patient has a history of clinically significant antibodies/special transfusion requirements) and transfusion is needed prior to the completion of antibody ID and/or acquisition of appropriate products.

 

Does your medical director/on-call pathologist get involved? Does the supervisor/manager/Lead/Senior tech get involved? Are there instructions for the selection of 'best matched' products? Are there special forms to be signed? Is this handled under the same policy/documentation as when a blood product is emergency released due to no type and screen specimen?

 

Is anyone willing to share some information or even their policy/process/procedure documents? Does anyone have any good reference articles about this topic or even an educational tool they used at their institution and would be willing to share?

 

Thanks in advance and happy Holidays!!

 

Literature that was able to be retrieved from PubMed:

Goodell PP, Uhl L, Mohammed M, Powers AA. Risk of hemolytic transfusion reactions following emergency-release RBC transfusion. Am J Clin Pathol 2010;134:202-6.

Johnson V, Langeberg A, Ahmad M, Sandler SG. Emergency transfusion of incompatible red blood cells [letter]. Arch Pathol Lab Med 2007;131:1514-1515.

Mulay SB, Jaben EA, Johnson P, Badjie K, Stubbs JR. Risks and adverse outcomes associated with emergency-release red blood cell transfusion. Transfusion 2013;53:1416-20.

Ong MG, Ezidiegwu C, Beadling W, Rosales LG. Re: Emergency transfusion of incompatible red blood cells [letter]. Arch Pathol Lab Med 2008;132:1386.

Saverimuttu J, Greenfield T, Rotenko I, Crozier J, Jalaludin B, Harvey M. Implications for urgent transfusion of uncrossmatched blood in the emergency department: The prevalence of clinically significant red cell antibodies within different patient groups. Emerg Med (Fremantle) 2003;15(3);239-43.

[L106]

I will start the ball rolling with how we handle some of the issues you have addressed:

 

1.  Antibody is present, but not ID'ed yet, and crossmatch is compatible:  We have a form that states that the antibody has not been identified, and although the crossmatch is compatible transfusing it does carry some increased risk because it has not been screened for the corresponding antigen.  Ordering physician has to sign the form.  (Pathologist is not usually notified.)

 

2.  Patient has a history of a clinically significant antibody and the crossmatch is compatible:  We have a form that states that, plus the comment that transfusing it does carry some increase risk because it has not been screened for the corresponding antigen.  Ordering physician has to sign the form.  (Pathologist is not usually notified.)

 

3.  Antibody is present, but not ID'ed yet, and crossmatch is incompatible:  We have a form that states that the antibody has not been identified and the crossmatch is incompatible and carries an significant risk of a possible hemolytic transfusion reaction.  Ordering physician has to sign the form.  Pathologist is notified that we are issuing incompatible blood.

 

The above situations are spelled out in our policies/procedure manual.

 

In any of the above situations, if the supervisor or assistant supervisor is present they are consulted and get involved in the situation (to make sure we are doing the best/safest thing for the patient.)  If supervisor or assistant supervisor are not present, whether they are consulted/notified depends on the expertise/experience of the tech involved.  All staff are certainly welcomed to call us at any time, but a few of our experienced techs are comfortable handling the situation.

 

Donna

[goodchild]

Thanks for your detailed response Donna.

 

Just out of curiousity, do you have a spot on the form for situations where an antibody is present but not IDd (and/or history of antibody) and blood needs to be released prior to crossmatch testing?

[L106]

Yes.

 

Our form that the physician must sign has areas for the following (and the tech checks which box is appropriate):

 

1.  Issuing incompatible blood.

2.  Antibody is present, not ID'ed yet, and crossmatch is compatible.

3.  Pt has history of clinically significant antibody and crossmatch is compatible, but unit has not been screened for antigen.

[mollyredone]

We use the same form for emergency release and high risk transfusion.  Most emergency release are issued before the antibody screen is done and they get O Neg or type specific if the type is done.  We require the form be signed but not before the units are issued.  If we know the patient has a previous antibody or the screen is positive, I insist that the form be returned to me signed before I will release the blood.  I don't want anyone saying "I didn't know there was a problem" after the fact.

[tbostock]

Same as mollyredone here.  We have the same form and we are notified to call the ordering MD also.  Usually the Blood Bank techs are more upset about it than the physician.  I always tell them that "incompatible units can be fatal, but bleeding to death is always fatal".  It puts it in perspective.

[mollyredone]

We did have a patient who came into the ER and we knew she had anti E and anti Fya. We had pre-screened units for E, but not Fya. The doctor insisted so she got two units. She had a lot of comorbidities and was transferred to a bigger hospital and died two days later. One of the units was Fya positive....

[Auntie-D]

We did have a patient who came into the ER and we knew she had anti E and anti Fya. We had pre-screened units for E, but not Fya. The doctor insisted so she got two units. She had a lot of comorbidities and was transferred to a bigger hospital and died two days later. One of the units was Fya positive....

 

But surely an empirical crossmatch would have picked that up?

 

In an emergency situation where there is a massive bleed, any reaction is going to be going on on the floor rather than in the patient anyway...

[goodchild]

Just to be clear with what you're mentioning, what exactly is an empirical crossmatch?

 

I've heard the aphorism before regarding massively bleeding patients and the reaction happening on the floor.

 

One of the reasons I posted this thread is to find out what other institutions do in the more ambiguous emergency release scenarios.

e.g. patients who are hemodynamically stable (or perhaps a slow, innocuous GI bleed) but are profoundly and symptomatically anemic and have a positive antibody screen (and/or history of antibodies).

 

Another reason was to find out how the decision making process works when blood is requested and there's known and/or unidentified antibodies. Does the technologist handle all of the discussion with physician and product selection? Does the technologist notify the pathologist? Does the technologist consult with the pathologist? Does the pathologist consult with the physician? Does your facility have tools (slow charts, procedures, etc) to guide the technologist for making the 'best' choices or is it left up to situation/experience/technical judgement?

 

I really appreciate the posts so far and want to keep the discussion rolling!!

[AMcCord]

We would definitely notify the pathologist and I would expect him/her to discuss the situation with the patient's physician to determine the best and safest course of action for that patient (which could include prescribing solumedrol, etc.). I have generalists here and they don't have the experience to have that kind of discussion, even with a process map to help them. Plus I think that this is something that calls for a review of patient status from a clinical standpoint to help guide the decision.

[tbostock]

 

 

Does the technologist handle all of the discussion with physician and product selection? Does the technologist notify the pathologist? Does the technologist consult with the pathologist? Does the pathologist consult with the physician? Does your facility have tools (slow charts, procedures, etc) to guide the technologist for making the 'best' choices or is it left up to situation/experience/technical judgement?

 

Yes, the tech would speak to the physician directly, and would be responsible to selecting the product. There are no specific guides for this, the tech would have to use judgment to select the best unit for the patient.  We have pre-screened units in the refrig that they could pick from.

 

No, the tech would only consult the pathologist if it was an unusual situation, as this scenario is covered in our policy for emergency release of blood.  The pathologist would then consult with the physician to see if he/she cannot wait for testing to be completed.

 

[Auntie-D]

Just to be clear with what you're mentioning, what exactly is an empirical crossmatch?

 

When you don't have antigen negative blood and you just crossmatch random units until you get enough that are compatible.

[mollyredone]

This was an emergency release situation, so there was not time to complete an "empirical" 40 minute crossmatch or the antibody screen.  The doctor declared it an emergency, not the blood bank.

 

As I said she had comorbidities, but we still had to write it up as being against protocol, issuing units that had not been screened for Fya.

[goodchild]

Is anyone else willing to share?

[mollyredone]

As far as our pathologist involvement, we don't call them for regular emergency release, unless we are running low on O Neg and might need to switch. They are also not usually contacted about high risk either, unless the doctor insists, or the tech has an incompatible crossmatch. Usually they want blood for the patient before we have gotten a crossmatch done if there is an antibody involved.

[goodchild]

Bump for further discussion. I really thought this topic would go further, granted it was started during the holidays..

[SMILLER]

Simular to Donna's post (second from top) here.

 

Scott

[ElinF]

We just have an emergency release form too.  Ours states "Because the delay in transfusion will jeopardize the patient's life, I accept the responsibility for any adverse recipient reaction resulting from this transfusion. I understand laboratory personell will compete the required testing and report immediately any unacceptable results."  Doc signs.  Kind of a catch all. 

 

The blood bank tech would be talking to the physician.  Usually when we say things like antibody or incompatible it scares them off enough to wait (if it is a chronic issue, slow GI bleed etc) until we are done.  If the patient is bleeding out they just get the O neg blood, but we do tell them of the situaion.  If there was an antibody situation the pathologist would be notified along with our lab manager and Nursing/Hospital supervisor.  

 

However, I like the forms stated above that make the doctor check which one so they know what they are getting and if it is compatible or not. 

[wellspl]

Does your medical director/on-call pathologist get involved? Does the supervisor/manager/Lead/Senior tech get involved? Are there instructions for the selection of 'best matched' products? Are there special forms to be signed? Is this handled under the same policy/documentation as when a blood product is emergency released due to no type and screen specimen?

 

 

 

 

We have an emergency release form the physician signs anytime product is issued prior to testing being completed.    We also have a "Deviation from Standard Operating Procedure" policy that spells out when the Medical Director/Patholigist needs notified. The senior techs involvement depends on the experience/comfort level of the technologist.  We are encourged  to call her if there are any questions.  Any time an emergency release form is completed we also fill out an occurence report to document what happened. 

[suhu]

We use one form "Emergency Release Form", with one statement when any products are released before testing is completed.  We add a bright Avery sticker  that says "Dr. sign and return to Station 118" . We send the form along with the emergency products, docs then sign and return.  We rarely have an unreturned form, although this did have a learning curve, as things were not so "quality controlled/managed" in the old days. The signature statement on the form reads "due to the gravity of the patient's condition, I am requesting the release of blood products prior to the completion of compatibilty testing".  Techs do notify  the patient physician for patient's with known antibodies, or positive/unresolved crossmatches/panel. We keep an inventory of unconfirmed pre-screened antigen typed units- so for the antibody patients we choose those units if we can.  If there is time for full crossmatching, we issue the serologically compatible units, but if the antibody id is pending, those crossmatched units are released under  Emergency Release process.

 

We are required to notify both the patient physician and the blood bank medical director if subsequent testing finds that an incompatible unit was issued.

[jojo808]

A late reply but we do pretty much the same as mollyredone. You either finish the workup completely (they would have to wait) or the ordering MD signs the emergency release form. There are check-off boxes on our forms. 1. ABO/RH not done. 2. Antibody screen not done. .3 Crossmatching not done. I can't remember the 4th.

 

As bloodbankers, our job is to completely finish the workup which means giving "compatible" blood. Anything less than that is technically "not compatible" (yet).  As medical doctors, they decide whether it is a life or death situation. They either sign the form or wait.

 

Correct me if I'm wrong but I tried to look up transfusion fatalities and I didn't see anything related to antigen/antibody incompatibility except with the ABO/Rh system. I don't think it would be fatal but certainly wreak havoc in vivo if a patient were given ag/ab incompatible blood especially in an emergency situation where the underlying condition for the emergency visit (anemia/hemorrhage) makes the patient vulnerable.

[tbostock]

A late reply but we do pretty much the same as mollyredone. You either finish the workup completely (they would have to wait) or the ordering MD signs the emergency release form. There are check-off boxes on our forms. 1. ABO/RH not done. 2. Antibody screen not done. .3 Crossmatching not done. I can't remember the 4th.

 

As bloodbankers, our job is to completely finish the workup which means giving "compatible" blood. Anything less than that is technically "not compatible" (yet).  As medical doctors, they decide whether it is a life or death situation. They either sign the form or wait.

 

Correct me if I'm wrong but I tried to look up transfusion fatalities and I didn't see anything related to antigen/antibody incompatibility except with the ABO/Rh system. I don't think it would be fatal but certainly wreak havoc in vivo if a patient were given ag/ab incompatible blood especially in an emergency situation where the underlying condition for the emergency visit (anemia/hemorrhage) makes the patient vulnerable.

Check out page 3 of the attached document; it shows fatality statistics for non-ABO incompatibility.

Annual FDA Fatality Report 2013.pdf

[AMcCord]

 

Correct me if I'm wrong but I tried to look up transfusion fatalities and I didn't see anything related to antigen/antibody incompatibility except with the ABO/Rh system. I don't think it would be fatal but certainly wreak havoc in vivo if a patient were given ag/ab incompatible blood especially in an emergency situation where the underlying condition for the emergency visit (anemia/hemorrhage) makes the patient vulnerable.

 

Actually, there seems to always be a small number of transfusion fatalities each year related to non-ABO antibodies. The stats don't tell us whether or not they were emergency releases or other issues (low titer, errors, etc). However............bleeding to death is always fatal. If the risk/benefit determination says the patient is going to die without the blood, the benefit of risking transfusion in spite of the potential for a  serious transfusion reaction is clear. In the case of a patient with an antibody I think it's critical to inform the physician that a serious reaction is possible so that the patient can be monitored very carefully, then give the blood needed to save a life.

Edited January 30, 2015 by AMcCord

[goodchild]

A late reply but we do pretty much the same as mollyredone. You either finish the workup completely (they would have to wait) or the ordering MD signs the emergency release form. There are check-off boxes on our forms. 1. ABO/RH not done. 2. Antibody screen not done. .3 Crossmatching not done. I can't remember the 4th.

 

As bloodbankers, our job is to completely finish the workup which means giving "compatible" blood. Anything less than that is technically "not compatible" (yet).  As medical doctors, they decide whether it is a life or death situation. They either sign the form or wait.

 

Correct me if I'm wrong but I tried to look up transfusion fatalities and I didn't see anything related to antigen/antibody incompatibility except with the ABO/Rh system. I don't think it would be fatal but certainly wreak havoc in vivo if a patient were given ag/ab incompatible blood especially in an emergency situation where the underlying condition for the emergency visit (anemia/hemorrhage) makes the patient vulnerable.

 

I'm not trying to discourage the release of blood in emergency situations I just want to know how the entire community handles some of the unique situations.

 

Here's the FDA report regarding transfusion fatalities. Fiscal year 09 through Fiscal year 13 there were 29 fatalities associated with antibodies other than ABO. Also bear in mind that these are only the ones that are identified and reported.

 

http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/ucm391574.htm

[Auntie-D]

I'm not trying to discourage the release of blood in emergency situations I just want to know how the entire community handles some of the unique situations.

 

Here's the FDA report regarding transfusion fatalities. Fiscal year 09 through Fiscal year 13 there were 29 fatalities associated with antibodies other than ABO. Also bear in mind that these are only the ones that are identified and reported.

 

http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/ucm391574.htm

 

But delay in the provision of blood in massive haemorhhage situations is far more likely to result in death than a transfusion reaction - the reaction is most likely to be occurring on the floor...