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One thing I would say is that the baby should be treated on clinical symptoms, rather than on laboratory results, particularly when they are so weak that you have to do all this testing to show an abnormality in the Blood Bank. A slight rise in bilirubin is normal in a newborn baby. This situation is very similar to the difference between a haemolytic transfusion reaction, where, for example, there is a positive DAT, antibody can be eluted and there is a SIGNIFICANT rise in bilirubin and a SIGNIFICANT drop in Hb, and a serological transfusion reaction, where there may, or may not be, be a positive DAT, antibody may or may not be eluted from the red cells, a new antibody specificity may be detected in the plasma, but there is NO SIGNIFICANT rise in bilirubin and NO SIGNIFICANT drop in Hb. Your cases remind me strangely of the latter.

We supply blood to a helicopter service with a contract with our hospital system. We put Safe-T-Vue indicators on all of their units. They provide us a copy of their in-flight chart when they transfuse anyone not coming to our hospitals. If the patient doesn't come to us but has an account in our HIS, we create a bogus registration in our BBIS using a defined format account number. If they don't exist in our HIS, we create a complete registration manually in our BBIS using a defined format for MR# etc. Then we emergency issue the product in our BBIS and handle it just as we would those patients who expire before a specimen is drawn etc. We charge the helicopter service for the products which they include in their flat fee to the patient. We maintain the final disposition records for any lookbacks etc. If we got a market withdrawal or lookback, we would notify the helicopter company to follow up with the recipient. That duty is at least vaguely covered in our agreement with them, I believe. We tell the helicopter crew to return any unused products to us and not to leave them at the receiving hospital but this isn't perfect. We sometimes transfer products on paper to the receiving site if we can document handling sufficiently. It doesn't work easily if the receiving hospital doesn't use the same blood supplier.

I have to ask, how many times when the DAT is negative and you can elute the antibody from the babies cells does the infant show symptoms of a significant case of HDN (old guy, old nomenclature) resulting in an exchange transfusion or even phototherapy? Seems to me you are doing an awful lot of work for little, if any, benefit. See Malcolm's technical discussion above.

Good news if anyone is still looking for a copy! AABB Press will republish the fourth edition of Applied Blood Group Serology, the influential reference book for blood bankers last published in 1998. This landmark publication is widely considered to be one of the most influential books for professionals in transfusion medicine and continues to be used as a reference for blood bankers throughout the world. AABB, in partnership with authors Peter Issitt, PhD; and David Anstee, PhD, will reissue the fourth edition prior the 2019 AABB Annual Meeting for a limited time only. Annual Meeting attendees may preorder Applied Blood Group Serology by contacting AABB Member Services (+1.866.222.2498) before Oct. 4. Those who purchase the publication prior to Oct. 4 will be able to pick up their orders during the Annual Meeting, to be held Oct. 19-22 in San Antonio. After Oct. 4, the publication will be available for the public to order. The publication will also be for sale in the AABB Bookstore during the 2019 Annual Meeting. To celebrate the rerelease of the book, AABB has added a special book-signing event at the meeting. Issitt and Anstee will participate in two book-signing sessions on Sunday and Monday afternoons from noon to 2:30 pm. The book-signing will take place in an area near the bookstore at AABB Central. Additionally, the upcoming October issue of AABB News includes an interview with Issitt.

We always used the last tube/column in a cassette that gave a macroscopic reaction. We certainly used "too weak to titre".

i ended up finding a reference that actually provided the half-life of rhogam, which is the product we use, and the minimum blood concentration needed to prevent immunization. it's the math behind the 28 week dose covering up to 40 weeks comes from, i dont know why neither I nor my BB manager learned this during our training! i also pinged a senior OB I trust about this stuff, and he said she's very likely covered by what she's already got, but can redose if so desired. So since we gave her 300 mcgs a week ago, we advised that she is very likely completely covered (she should still have almost the full dose in her system just one week out), but that OB can dose again if she feels squirrely about it. D. Salkin, thanks for your input! sounds about like what i ended up with.

If they have a historical type on file, you do not need a current T/S to issue plasma and platelet products. For RBCs you do need a current T/S.

This is something I found on the CAP website: (For some stupid reason I did not copy the URL.) From the CAP website: Optimum timing of post-transfusion phlebotomy is critical for ensuring meaningful laboratory testing results, and medical judgment is required in making this determination. Several factors must be considered, including the type and amount of blood product given, purpose of the test (that is, the question it is intended to answer), and clinical setting. In general, it is best to perform phlebotomy when the patient’s circulatory system is in homeostasis. A patient who is bleeding or undergoing blood product transfusion, or both, is not in a steady state. Whenever possible, samples for laboratory testing should be postponed until bleeding has stopped and transfusion is complete. One obvious exception to this rule, however, would be the setting of massive transfusion, during which monitoring certain laboratory values, such as cell counts and coagulation parameters, is essential to guide ongoing therapy. Variables such as patient blood volume, cardiac output, renal function, and volume of blood products transfused affect how quickly homeostasis is achieved following transfusion. For the evaluation of post-transfusion increments in hemoglobin, hematocrit, and platelet counts, a practical approach is to draw blood samples within 10 to 60 minutes after completing transfusion, as this time interval is aimed at measuring peak recovery.1 Results determined from blood samples drawn later than 60 minutes post-transfusion are increasingly affected by confounding conditions, such as splenic sequestration, sepsis, and consumption.1,2 If the intent is to determine the extent of such confounding processes on red cell and platelet counts, one should combine a 10-minute post-transfusion sample with sequential samples drawn at one hour and 24 hours post-transfusion. Alterations in chemistry test results following transfusion are not usually a concern in the low-volume transfusion setting. However, assay results may be affected for varying periods following transfusion of large amounts of blood products, as seen in massive transfusion, red cell, or plasma exchange—particularly if the recipient has impaired hepatic or renal function. Banked storage of red cells results in elevated plasma levels of hemoglobin, potassium, LDH, and iron in the blood unit that may, particularly in the metabolically impaired patient, be reflected in the post-transfusion laboratory values. In addition, citrate anticoagulant present in blood products may result in transient hypocalcemia in the recipient.3 Therefore, following large-volume transfusions or exchanges, waiting 12 to 24 hours before drawing samples for chemistry assays will provide results that are more reflective of the patient’s underlying metabolic state.

Partial DVI is the single most common partial D found in the White populations, having a phenotype frequency of between 0.02 and 0.05% in these populations. Have a look in Daniels G. Human Blood Groups. 3rd edition, 2013, Wiley-Blackwell and/or Klein HG, Anstee DJ. Mollison’s Blood Transfusion in Clinical Medicine. 12th edition, 2014, Wiley-Blackwell. You will find several references in either or both of those books. Alternatively, look for http://www.rhesusbase.info/ in your search engine (which is a superb site). It is only really necessary for the "donor side" to look for individuals with Partial DVI. There really is minimal evidence (even that is stretching it) that foetuses/babies who are Partial DVI can cause their D Negative mother to produce an anti-D, but it would be almost impossible to put that particular genie back in the bottle! That having been said, in my experience, the moment that people find that the baby is a Partial DVI, they shoot the mother full of anti-D immunoglobulin, without ever testing the mother to find out if she is also a Partial DVI. One day, a virus, unknown at present, will be passed on in the anti-D immunoglobulin, and it will be proved that it need not have been given in the first place, and then, all Hell will be let loose.

The final came out on Sept 20th, no longer a draft. We have 18mths to implement. Bacterial-Risk-Control-Strategies-for-Blood-Collection-Establishments_09-2019.pdf

We have had Routine Antenatal Anti-D Prophylaxis (RADDP) in the UK since August 2008 (National Institute for Health and Care Excellence (NICE). Routine antenatal anti-D prophylaxis for women who are rhesus D negative. Technology appraisal guidance (TA156). Published date: 27 August 2008) - please excuse the word "rhesus"; they were told about this before publication, but they ignored all advice. The following quote is from Qureshi H, Massey E, Kirwan D, Davies T, Robson S, White J, Jones J, Allard S. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine 2014; 24: 8-20 (doi: 10.1111/tme.12091), "A direct antiglobulin test (DAT) on the cord blood sample is not routinely performed since it may be positive in a proportion of cases because of antenatal prophylaxis with anti-D Ig. However, a DAT should be performed if haemolytic disease of the newborn is suspected or anticipated because of a low cord blood haemoglobin concentration &/or the presence of maternal immune red cell antibodies." From this, it can be seen that the phenomenon you describe is far from unusual, and extensive trials went on as far back as the early 1960's (Finn R, Clarke CA, Donohoe WTA, McConnell RB, Sheppard PM, Lehane D, Kulke W. Experimental studies on the prevention of Rh haemolytic disease. British Medical Journal 1961; 1: 1486-1490. doi: http://dx.doi.org/10.1136/bmj.1.5238.1486, and no evidence was found that the fetus or newborn would be affected by this passive anti-D, even with a slightly raised bilirubin, which, is normal anyway, as HbF production is "switched off" and replaced by HbA production.

As long as you validate/verify the digital, I believe annually is the requirement, you should be fine without a second thermometer hanging around waiting to get broken.

We do not recommend infusion rates. That is the purvue of the ordering MD (anyplace I have ever been). The only thing I tell nursing is to infuse plts as quickly as prudence dictates.

I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs. Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive. Then everyone else is scattered around in between these 2 extremes. Then throw in the males and women who are beyond child bearing and it becomes even more complicated. I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.

We are persuaded that sending plasma and platelets in a first cooler harms more patients than it helps. We actually wait to provide plasma and platelets/cryo until we are told this is a massively bleeding patient or 8 red cells have been sent. First cooler is 4 red cells. Second cooler is 4 red cells, if needed. Almost all the time, none or few of them are used. We are the only level I trauma center within 70-80 miles. Thus including plasma and platelets, which are highly toxic products, associated with nosocomial infection, multi-organ failure, thrombosis and mortality, will likely lead to the occasional patient receiving them along with one or a few red cells. A recipe for increased harm with no benefit. I realize this goes against the grain of what is being recommended, but the experts in surgical trauma are resolutely unaware or in denial about the risks of transfusion in patients in whom transfusions are not life saving. Reasonable, to my way of thinking, to reserve plasma/platelets and cryo for patients who are truly massively bleeding and will die without transfusion. Even then, I'd recommend tranexamic acid and/or DDAVP, and possibly fibrinogen concentrate (or cryo) long before transfusing plasma and platelets to bleeding patients, based upon randomized trial evidence to date. Remember that early use of plasma and platelets has never been tested against these other modalities in randomized trials. Platelet transfusion in particular, has promoted bleeding and mortality in randomized trials to date, and should be avoided if possible. Particularly ABO non-identical transfusions which almost certainly make bleeding worse, not better.

Complement isn't bound at AHG phase. You detect it there if you are using Polyspecific AHG. In Ortho's gel I find significant # of anti-M's at ahg even though I'm using an anti-IGG card. M's like the slightly acidic environment. It can attach if you delay putting the cards or tubes into 37C environment. I think the biggest surprise from colds is when you've done a preop screen which is negative. Later you set up in ISxm only to have it be positive . . . I know I'm not helping you a lot. Seems this question is based on your previous one about colds.

Agree with Ward's points, above. Any change in policy will involve discussion with ER, Surgery, etc. that includes education once a decision is made. When we became a level 2 truma center a few years ago, we had a rather elaborate MTP process that included things like Coag and CBC results. We have two different orders for emergent situations: An "Initial Resusitation Cooler" order (2 RBCs, 2FFP), and an "MTP Protocol" order (5 RBCs, 5 FFPs, 1 5-pk platelets). We repeat the MTP order until it is called off. In addition, individual orders for uncross matched products can also be made. Scott

I wholeheartedly agree with all the above comments for you to determine the surgeons expectations. One other thing we found VERY useful was asking if the patient has had prior heart surgeries, i.e. how much scar tissue was on/around the heart. We found that the more scar tissue the patient had the more products, especially RBC, would be needed.

In the long ago past, we had to make up our own validations. While not realizing we were doing so, we based them on risk assessments of the process. For instance, what is the risk of switching your Anti-A from one vendor to another? If you follow of the manufacturer's instructions, and they are both licensed by the FDA, the risk is close to zero. In my humble opinion ABO QC is a waste of time. In the tens of thousands of times I've seen it performed in our organization, it has never failed. Regardless, yes we perform QC. Now, you buy a complex analyzer, it is nearly impossible to develop a good risk assessment without the assistance of the vendor. I always start by asking the vendor for a validation plan. Some provide Word docs that you can edit for your own facility. We always do what they recommend at a minimum, and usually more. We've been lucky in that our vendors provides these plans. Moving forward, that will also be part of my negotiation for new equipment, that I will ask for them to include a validation plan.

We have had open heart surgeries here for years. A few years back, anesthesia and one of the heart surgeon got a wild hair to have TEG. It has been a major waste of time and money. We had the results feed live into the OR so that they could see them. The company came in a gave them all instructions on the system and how it could help them determine what blood products they needed. They have never used it to make decisions during surgery. Regardless of the results, if their patient is bleeding, they are going to want plasma, platelets, and possibly cryo. We are currently keeping 1 plt pheresis. 2-4 prepooled (5 cryo/pool) cryoprecipitate in house on the days that we have surgeries. We've started keeping 2 A plasma thawed at all times. Most CABG procedures require few products, Valves Replacements can be bigger users.

FYI: the draft guidance was implemented 9/30/19 and we have 18 months to comply.

I would think that the rephrasing was to emphasize that is is the reagent in the vials (not just the vials themselves!) that expires after 7 days. I think it is clear that they are saying they claim the reagent is stable for 7 days after opening. If I were an inspector, I would interpret the new phrase as indicating that the "performance characteristics" end after being "maintained" for 7 days, which would mean that you cannot use a vial after that time. Scott

JAT-C Got to the bottom of it with one of them, it was Anti-c antibody positive and was cold reactive with the A cells. Switched for some c- cells and now clear.

We do. We use plain clear zip lock bags. We have used biohazard bags in the past. We stopped because there was a concern that the patients might think we were giving them biohazardous units.

Hi all! I'm a recent MLT grad (2 years) working in the DC, MD, VA area and will be continuing my education in the Spring to complete my BS, MLS! I'm excited to learn from this forum!

As far as I know, FDA currently has a draft guidance for pathogen reduced platelets. FDA recently came out with the final regarding bacterial risk and platelets. You can search for FDA guidance's any time. Copy this link https://www.fda.gov/regulatory-information/search-fda-guidance-documents

We use a titer value of 0 (zero) to indicate absence of agglutination or less than 1+ agglutination in any tube.

We don't ignore the "weaker" agglutinations -- we still record M reactions... however, the result of the titer is the last dilution that is graded >M (i.e. is graded 1+). We have a test result called "below titerable levels" for a titer that doesn't have reportable results similar to what you are describing.

We keep RBC and plasma on our helicopter using the Pelican Credos and a datalogger. Units are changed out every 24 hours or replaced when transfused and they keep extra sets of credo panels in the ER freezer to follow manufacturer IFU. Dataloggers record temperatures every hour with an audible alarm to the user if the temperatures exceed 6C. Datalogger data is transferred to the Blood Bank for review and retention. We are looking into keeping units with supervisor units for ground transport in 3 counties but that is still in the works. If you can install an undercounter BB refrigerator at the airport with Wi-Fi temperature reporting and 7-day continuous chart recording, that may be another route to investigate. I have worked at a facility with remote storage at the heliport that was maintained by both ARC, hospital and air ambulance services. All have to work together to meet requirements to ensure that blood products are maintained properly.

We limit our matching to a group that is generally manageable. It has been some time ago since I looked at their recommendation, but the Sickle Cell Foundation was recommending matching further than we do. We do find that these patients develop 'warm autoantibodies' which I think are or may be a reflection of the myriad other antigens that we do not match. That being said, our practice has been successful in preventing stroke overall in a disadvantaged and usually overlooked (in my area) group of children. We have done a pretty good job of indoctrinating the patients and their families to get in touch with us when our patients go to another facility.

That is what we all said at my facility, none of us could figure out why anyone would think that was necessary!

Standard 62. Transfusion therapy. Infusion therapy standards of practice. (2016). Journal of Infusion Nursing, 39, S135–S137. (Level VII) and AABB. (2012). Primer of blood administration. Bethesda, MD: AABB. (Level VII) these are the references that our blood administration policy lists.

I know of blood banks who have been AABB Assessed and NOT have had to have a CAP blood bank inspection. Both are CLIA deemed status. No need to have both (for Blood Bank).

Thank you, Carol

The patient is long gone. But the same method -- manual gel -- was used for both the screening cells and the panel cells. As I mentioned, the reagent cells were both all R1R1 (but from different donors)--yet only the cells from the one screening set was negative. Had to be something wrong with that particular cell and that particular patient. Scott

Hi Malcolm, I am a new member and just read this topic and I like to say that is honorable to be recognized for your contributions to transfusion medicine. It is exciting no need for apology Very glad I joined the society of transfusion medicine.

Are you using solid phase by any chance? We have seen solid phase does that, since a lot of our hospital used solid phase method. When that happened, we usually look for antibodies using PeG Tube method or by testing ficin-treated cells. We were usually able to find the suspected antibod(-ies) except for Kidd antibodies. You may be looking at some method-dependent antibody? Anti-C in your 2nd sample may be stronger than that in your first sample? What is the patient's ethinicity? Is the patient e- or e+? I am also thinking about anti-Ce like antibodies if you see this anti-C reacting stronger with e+ cells than e- cells.

A photograph to back up galvania's comment. IgA DAT.pptx

We give O= unxm only to females of child bearing potential (<50 yo).

We do the same for our traumas. I think its a common practice. Scott

bevydawn1, Here is the rule I had in 5.67. Hopefully it helps. The Data Flds From is BSP. (([f bsp ctime]-2400)/100)^X, (72-X)^Y, [f bsp exp hrs set](Y);

Malcolm, thanks so much for the article. It was very helpful. As it turned out, we sent mom's sample to our reference lab for MMA testing, and we also antigen typed her 2 brothers and her father. One of the brothers matched her Duffy and Kidd antigen types and was Coombs crossmatch compatible with her. He donated two units of packed red cells (at one donation) and was also confirmed to be Diego b negative. The patient's anti-Dib came back as clinically significant based on the MMA test. She did have a C-section after all and did not require any blood! The baby had a negative direct coombs so there were no issues there either!

My own questions would be, firstly, what on Earth are you doing identifying the RCI Laboratory concerned (poor form) and, secondly, what on Earth are they doing wasting public money by proving the presence of an anti-G in a 92-year-old patient, when knowing the exact specificity of the Rh antibody/antibodies in the patient's plasma will make no difference to what blood she will be given, should she require a transfusion?

Your post suggests that patients who initially type group O should be tested a second time for not only ABO, but also Rh and Antibody Screen. I assume you would include the same testing (ABO, Rh and Antibody Screen) for non-Group O patients. I disagree. Does anyone (US and UK) in this forum repeat the Antibody screen on the same sample or a newly collected blood sample? Repeat the Rh? The concept of a second ABO typing did not emerge until after the "Computer Crossmatch" became an alternative method (to the serological crossmatch) approved by the FDA in the late 1990’s. Repeat testing of the same sample or a newly collected blood sample for Rh and Antibody screen was not required by the FDA, AABB or the CAP. A second ABO typing is intended to be a serological alternative to the Immediate-spin Crossmatch to confirm the patient's ABO determination when a "Computer Crossmatch" is done. This creates a process that is similar to that done for donor units, i.e., blood type determination by donor center and blood type confirmation by the Transfusion Service. In the absence of a "Computer Crossmatch", a serological Immediate-spin Crossmatch is required to detect ABO incompatibility between donor and recipient and most patients are transfused based on a single ABO determination without any repeat testing for Rh or Antibody Screen.

In the US, all accrediting agencies must satisfy CLIA, and Blood Bank regs are based on AABB standards. So AABB standards are already in use by JCAHO, CAP, etc. Scott

Hello Pmanager, ISBT 128 does not preclude the use of an additional label on top of the ISBT 128 label, such as the “Irradiated” label you referenced, as long as it does not obscure/cover any of the ISBT 128 information. I hope this helps! Kind Regards, Kaytee from ICCBBA (Organization that maintains and develops the ISBT 128 Coding and Labeling Information Standard)

I'd love to be able to get these cards in the USA. However, they are not available for us at this time.

This is true Mabel, but it is far from fail-safe. We have had numerous cases in the UK (where treatment under the NHS is free) of identity theft, where a person not entitled to free treatment has come in to hospital having learned all the details of a person who is entitled to free treatment, and we have detected the fraud by them having different ABO groups and/or D types to the person entitled to treatment, or no longer have an antibody that normally remains in the circulation for decades.

I was new to my compliance officer job. I was hoping to learn more than teach. I assessed one organization that almost made me cry. I asked for anything from section 1 in Standards, they had nothing. I asked for training documents, they gave me beautiful blank ones, but none that were completed for any staff. The whole assessment went like that. I went to lunch and was so overwhelmed with a sense of doom for them, I almost wanted to leave. Most of the places I went were similar. I stopped as it was just too draining on me.

A number of years ago the President made a visit to our area. His advance team visited our hospital and the blood bank. They asked if we were AABB accredited which we regrettably answered no. We are accredited by the Joint Commission Consequently our blood bank was told we could not provide blood product in the event of a medical emergency!