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I've never heard of that. While I can understand the rationale, I'm afraid that if there was enough of a fetal bleed to impact antigen testing mom there are bigger problems than just getting the antigen type right. Just my thoughts.

Not a sensible approach in my opinion. No real chance of mistyping due to fetal bleed. At very least, you'd see a mixed field if there were a fetal bleed with a different type. So get rid of this requirement in my view.

Thank you all very much for your responses. I'm glad to hear that this is not a common practice and I do agree that the risk of mistyping would be extremely rare. This was my first time as well seeing this kind of practice. Definitely worth an SOP change.

I've been Blood Banking for 35 years......... (albeit in the same hospital) but I've never heard of that - nor do I know of any AABB or CAP regs that would imply that...... (and we've just been inspected by both!)

Most blood bankers I know have a pain tolerance only slightly less than their resistance to change!!

With pictures???

Agreed. I would however like to add the caveat that some physicians do not understand the risks associated with antibody history and uncrossmatched blood, so getting a pathologist involved to ensure the situation is truly life/death.

Stop blaming the Canadian Smoke. We in Canada, do result as No Antibodies detected. If the patient had an antibody in the past, that is maybe below detectable limits, but was previously identified, those are also in report as historical and as such the patient would have a full crossmatch in gel as well as phenotypically matched for previously discovered antibodies.

In the UK, it is STANDARD practice in all laboratories that I know to use either the phrase "No Antibodies Detected", or, more frequently, "No Atypical Antibodies Detected", as the latter also includes such things as the iso-antibodies of the ABO and H Blood Group Systems. Indeed, some go further still and use "No Atypical Allo-antibodies Detected", as this covers such findings as an auto-anti-H, auto-anti-I and auto-HI, as well as the ABO and H iso-antibodies. These phrases do not mean that there are no atypical allo-antibodies detected. It would be an incredibly rare set of screening cells and antibody identification panel cells that would both express, for example, the HJK antigen, or any other genuine low prevalence antigen. In some cases, where an atypical allo-antibody IS detected, but it is known to be clinically-insignificant (such as anti-Kna), we may use the phrase "No Clinically-Significant Atypical Allo-antibodies were Detected" (or words to that effect). One thing is for certain, and that is that a UK Reference Laboratory (and most hospital laboratories) worth their salt would report out as "Negative", or "No Antibodies", although, even using the phrases I've quoted above, occasionally the phrase, "All Clinically-significant Allo-antibodies have been Ruled Out using etc.", or words to that effect. MIND YOU - you have to remember that I am RENOWNED for being a pedant - but I learned it from a few good sources; Peter Issitt, Carolyn Giles and Joyce Poole (to name but three).

Another thing to try to increase sensitivity (other than PEG or other enhancement) is to increase the serum/cell ratio in the screen/indirect antiglobulin test. If there is no reactivity with enhancement, enzyme treated rbc (agree with Malcolm's caveat that some antigens will be destroyed) and increased serum/cell, one can be more confident there is nothing detectable pre-transfusion. Some consolation at least ...

Extended cross-match, UNLESS, the history of which other hospitals the patient has been treated is known. Of course, in the UK we have a national database of patient's antibodies, which makes life an awful lot easier, even if the data is just a "snap shop".

Give this a try. https://www.nist.gov/pml/time-and-frequency-division/time-distribution/radio-station-wwv/telephone-time-day-service

The trouble was that, in those days the anti-D immunoglobulin was known as "anti-D for Mum's Bums" in the UK, as the shot was given in the gluteal muscle. But, there was an awful lot of fat in that muscle, so the anti-D had a habit of "staying there", rather than being adsorbed into the blood stream. This meant that, even when the dose of anti-D immunoglobulin was calculated from the Kleihauer-Bekte test, the actual dose reaching the circulation was far lower than the calculated dose, and women used to produce allo-anti-D as a result. Nowadays (at least in the UK) the shot is given in the lateral deltoid muscle, where there is a good deal less fat, and so the shot is adsorbed into the circulation much easier, and so there are fewer cases of maternal allo-anti-D. I realise that this is a very vague explanation, and that there are many other causes of anti-D immunoglobulin being less than effective (such as giving it to the father, or even to the ambulance staff (SHOULD be unbelievable, but is actually true), but it does show just how complicated such a simple thing as this can be.

Concur with the above. It would have be a very serious F-M bleed to impact phenotyping. While there is a theoretical risk of mixed field, and potentially spurious interpretation of the results, if a gravid patient develops an antibody that late in the gestation, the very small risk of mistyping/reporting is worth taking.

Just curious, do they want the documents sent electronically or hard copy? Either way, especially since you referred to the request as a "big list" I would probably, respectfully decline. I would indicate that the listed documents would be readily available upon their arrival. But that just me and I never had an inspector request anything like this. I'm sure things have changed since my last CAP inspection.

Have you thought of thumb screws????????!!!!!!!!!!!!!!!!!!!!

Agreed. The ONLY time we might perform anything like a post-partum screen is if the baby's DAT is positive, and the baby has clinical signs of HDFN, but the mother has not been shown to have an alloantibody in her circulation during the pregnancy. In such a case, we may well test the maternal plasma (or an ABO adsorbed and eluted sample of the plasma) against the paternal red cells (if available) to see if the antibody is directed against a low prevalence antigen expressed on the paternal red cells. Having said that, however, this would only be useful in a further pregnancy with the same male, as providing the present baby with a unit for top-up or exchange would be easy if the antibody is directed against a low prevalence antigen

I am not sure I understand your question. If the mother had an admission type and screen and was rh negative, then all that would be required post-delivery is the fetal bleed screen. Why would you want to repeat and antibody screen post delivery?

Believe me when I say that you are lucky!

For an antibody screen “Neg” or “Negative” has been historically used. This may have been heavily influenced by DOS based computer systems that had very limited memory so “Neg” made sense. Reporting a SCREEN as negative seems logical to me, however a work-up requires more detail as Malcom’s described above.

I meant that they would NOT report it as "Negative", or "No Antibodies", but WOULD report occasionally as "All Clinically-significant Allo-antibodies have been Ruled Out using etc.", or words to that effect.

The USA is considerably larger, we do not have a national healthcare system (which I personally hope we never have), and there is not a central data base that is accessible to all. I'm afraid the cost / benefit analysis of establishing such would not favor attempting one. Just my opinion.

I agree with Malcolm. I would dig as deep as possible to find that antibody history. If none can be found, I would do AHG crossmatches. If it was a frequent antibody, the titers should rise to detectable levels soon.

I always based my judgement on the fact that the original studies to determine significant titers were done using double dose cells. Plus, nowadays, with donor eggs, the baby can be homozygous for the antigen.

There used to be a regulation that the birth parent not be sensitized to D to be a RhIG candidate. We trust that the baby lacking a positive DAT due to anti-D is sufficient evidence and have not done anything but the needed Fetal Screen in a couple of decades, even when we didn't do admission T&S routinely. I think key is what will we do differently with the results? If you detect anti-D, you will assume it is RhIG and give RhIG again. If the Ab screen is negative, you will give RhIG. The test doesn't change the treatment so why do it? This assumes that a strong anti-D, clearly due to sensitization, would cause the baby to have a positive DAT and therefore any needed workup would be completed for that reason.

we use a calibrated stopwatch

If we've done an antibody screen when the patient was admitted, we cancel the screen on the RhIG workup. If the patient only had a blood type ordered on admission, we do a screen.

Lol. Do you have a validation guide and procedure for that?

My experience came from transfusing a patient with an Adsol unit that was unwashed containing plasma antibodies. The patients were transfused with the unit and subsequent sample showed demonstrating antibody - it was more than 5 years ago so I can't remember how long the reactivity lasted. There was no transfusion reaction as the recipient, as I recall, was Rh negative and transfused with a unit containing anti-D. We could come up with no other reason for the patient to have a sudden appearance of anti-D when only transfused with Rh negative RBC - record check revealed that one of the transfused units contained anti-D.

Malcolm, my questions were directed specifically to applejw and the several examples mentioned. I was assuming they were fairly recent, at least in the last couple of decades and that info might be available. In 1967 I was in Jr. High and did not even know there was such a thing as blood banks!

We do not accept units from our regional supplier from donors with alloantibodies.

Well, the first thing to say is that red cells CANNOT be either homozygous or heterozygous (or, come to that, hemizygous). These terms apply ONLY to genes, and red cells do not contain a nucleus. The antigens can only be described as, at best, "homozygous", "heterozygous" or "hemizygous" expression, or, alternatively, "double" or "single dose" expression. Then, it HAS to be accepted that, unless the maternal antibody is an autoantibody, it must be an alloantibody (or, possibly, an isoantibody), which means that to mimic the state of the foetal red cells, the red cells used to titrate the antibody MUST have a "single dose" expression. However, that in itself presupposes that the foetal red cell antigens are all expressed at the same time, which we know is untrue (just look at the A, B and H antigens as an obvious example, but also the Kell antigens that are expressed much earlier than are the Rh antigens) or are ONLY expressed on foetal red cells, as opposed to other tissues (such as on the placental cells, which have, in some cases, been proved to adsorb the maternal antibodies). Then, there is the fact that not all antibodies can be detected by all techniques. This is why Reference Laboratories SHOULD have more than one technology available (and their workers should be provably competent in these techniques. However, even then, not all techniques can predict the severity or otherwise of HDFN. For example, antibodies within the Indian Blood Group System always show that they can cause severe HDFN by certain techniques, such as MMA, but they don't! There is also the fact that the immunoglobulins may be IgM, IgA, IgG1, IgG2, IgG3 and IgG4 (to mention just a few), and I have yet to come across, or read about, an IgG4 immunoglobulin causing HDFN. So, my answer is that there is a HUGE amount of knowledge known about the various antibody specificities, their titres, the expression of their cognate antigen, etc, etc, that there CANNOT be a single answer to your excellent question, but that the best thing that can be done is to read around the subject - and read around the subject from every source available - not just from a single country. OKAY THEN, RIP ME APART!!!!!!!!!!!

You did everything that was required in this situation. The patient was a trauma and needed emergency transfusion. The risk of death outweighed the risk of a hemolytic transfusion reaction in that scenario, according to the treating physician. I once had a trauma surgeon tell me "I can treat a transfusion reaction but I can't treat death!" That put things in perspective for me. That is why thy sign the consent. Next step would be to report this to your risk management department so that follow-up can be made, including monitoring the patient for the s/s of DTR.

We have seen this too quite a few times. We jokingly call them "gelibodies".

I've attached copies of our procedure and our worksheet. Our Heme/Onc docs also order them on our patients post-transplant, and we occasionally get them ordered on kids where they suspect some sort of immune deficiency disease. TO-310 Isohemagglutinin Workup - Test and Titer__uncontrolled_copy (2).pdf TO-310F01 Isohemagglutinin Test and Titer Worksheet__blank_copy_id_8428444.pdf

Im guessing since uk has a national database that this happens alot less. The usa should have something similar. Is there statistics on anamnestic response? How often have you delt with it?

The trouble is that, if the antibody happened to be an anti-Jka or, worse, an anti-Vel, the resulting rise in titre, following an anamnestic response, could be fatal on rare occasions.

Oh yeah.... that dates us. And I remember doing antibody screens post RhoGAM, prior to patient discharge, to 'see if the RhoGAM dose was adequate'. No anti-D detected = give more RhoGAM. Something the OB folks thought seemed like a grand idea before the fetal bleed screen was available. Fortunately fetal screens came out about then. We were able to convince the docs to stop with the ABS orders by running parallel tests with the fetal bleed screen for several months to demonstrate how meaningless the antibody screen idea was..

PathLabTalk would like to wish all members celebrating their birthday today a happy birthday. AMcCord --xmbeti (60)tmsmach4 (53)waselh (40)LainieC (53)Lisa J (54)weakpos (74)attassunc (41)

Inspection proof is a section of MediaLab where you can upload accreditation checklists and track how you are meeting them. Similar to AABB Apex self inspection but more robust. You can link and quote SOPs if you use the document control feature and flag any deficiencies and document corrective action like uploading an SOP revision. Makes inspecting a breeze for both sides. Only caveat is you have to upload in excel format and I’ve never seen joint commission provided that way. I have an email out to my medialab rep.

Ah ok. Makes sense. Cheers

I think they're meaning don't repeat the ABID on a post partum positive screen when you've already performed the ABID on the admit type and screen likely done within 24hrs of each other.

They requested by e-mail and haven't sent any official sharing links so I guess there expecting them back by e-mail which from what I've found from the CAP website is not one of the acceptable ways of sharing documents in advance., and yes, the list is 3 sides of A4 paper long so its a pretty large list. I did find the below on the CAP website, and it seems there is an option to "Opt" for advanced document review, however we have not, so I think we will be declining this. Thanks

There is one danger in this process, and I have seen it happen. Miscommunication between shifts opens the possibility of an expired unit being successfully issued because the expiration date in the LIS is different then what is manually written on the unit. If you are not changing the expiration in the LIS, you will need some sort of system in place (in policy and practice) that shows you mitigate this possibility.

If I'm not mistaken, both of those examples were whole blood units, not packed RBCs or RBCs resuspended in ADSOL. That would impact the amount of antibody transfused.

We accept patient (and unit) antigen typing done at our reference lab. I don't see why this would be different. You are there reference lab for anything that is beyond their limited ABID scope, right?

This is awesome! As many times as our freezer has gone done over the years, we never thought of putting dry ice in the freezer. Your dad is awesome!!!

Best story/advice I've heard in a long time!!! Thanks for sharing it.

We have used DI water in ours for years at the other location and at my previous employer and nothing has ever happened that is corrosive. Our tap water is far from acceptable to use so we steer clear of that. We have the manual and did see that statement. I only ask this because the supervisor before me attempted to do a study and cultured the water for a month and nothing ever grew, but since the research was not done correctly, it could not be used to extend the cleaning time. Thanks for the advice!

Cerner allows us to extend the date of the Preassess sample. If no pregnancy or transfusions, and a prior history or second sample drawn for confirmation of ABO/Rh, sample good for 4 days with OR day being day one. Not to surpass 30 days sample date. EXM still applies when sample date is extended.