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What about RH pos plasma products or platelets? Though they don't tend to cause an anti-D, they can "spike" one that dropped below detectable levels, I believe. And that far back, if any platelet concentrates were given, they would have had more RBC exposure than they do now with platelet pheresis units. Just a thought.

As Joanne mentioned above, no system is fool proof and there are lots of creative, inventive fools to prove it. Keep your system as simple as possible which should minimize the need for creative people to find ways around it. Now to your question, does it actually help prevent problems? Probably a few but certainly not all! I've seen people become lax in their diligence when they assume they are protected by the system. They seem to assume that if they make a mistake someone down the line with catch it. This is something to be avoided if possible. The only way that I know of to prevent this type of mind set from developing is through education and convincing everyone involved in the process that their step is critical and by keeping it simple they will be more likely to perform their step as instructed.

All the talk about statistics is great but in the real world you never know: I once screened over 30 units for K. All were positive. As I was the night guy, the day folks were laughing until they got the same results. All we could figure is the blood center was screening for K and shunted all the +s to a shelf which we received in bulk. I've also screened for Fya in past. Once i screened 4 units and found 2. The next time I had to screen 16 and the last 2 were negative. As I said, the stats look good but reality is sometimes a bit different.

We used to have sign in our BB: The Buck Stops Here. Of course someone altered the posters to "The Buick stops here". My boss was pissed off about that. The concept being that if you have a system of multiple checks and balances you better make sure the first one works. I have seen this concept evidenced too many times in my career. People get complacent.

No products/components since 2016 (see my previous post) TO OUR KNOWLEDGE. Being a small island nation, patients quite often get treatment in the UK which we don't know about and vice versa - very helpful. So he may have had D pos platelets. I think it unlikely he had D pos red cells for a planned procedure. We did XM 4 units (O neg) in 2016 but none were required. Thanks all

In terms of the function of the various ABO blood types, there have been a huge number of peer-reviewed papers written on the subject (and the number has exploded with the advent of COVID19). I would seriously defy anyone to keep up with all of these, but I would recommend reading pages 42-43 of Reid ME, Lomas-Francis C, Olsson ML. The Blood Group Antigen FactsBook. 3rd edition, 2012. Academic Press. ISBN: 978-0-12-415849-8. In terms of how they evolved, it is so far back now that it is anyone's guess, but slides 28 to 32 of the attached lecture may give you some idea. In Depth Lecture on The ABO and H Blood Group Systems.pptx

I always 'balk' at this idea because as we all know, the probability of two patients having the same blood type is high. We have had a few instances over the past few years where a wrong patient was drawn (we use BB Bands so it's very obvious) and they were the same blood type but one had antibodies and the other didn't. And yes, there are those who have had to come up with 'defensive measures' to 'assure' that there is no 'cheating', e.g. RN draws 2 samples and holds one in case the BB asks for a second, a witness (do you really think that happens as intended?), different colored tubes for the second draw (assuming they don't draw the wrong patient twice). I could go on and on about this ... but that wasn't your question, was it?

I agree with those who 'don't bother' with the actual math ... between 'natural selection' and blood suppliers 'holding' certain antigen types, exact math is just an academic exercise. To be practical (considering tech time and reagents are valuable commodities): If the patient's plasma contains demonstrable antibody, crossmatch a batch or two of units then do the antigen typing on the compatible units only. No luck = order antigen-neg from the supplier. If the patient's plasma is negative, then screen (highest frequency first) a batch or two of units. Again, No luck = order antigen-neg from the supplier.

I was thinking the same - and I have seen this scenario.

ABO mixed field must be explained; find out patient transfusion history. If it is not clear what their blood type is, or if the mixed field cannot be explained (patient intubated, confused etc.) document and give type O. Interpretation of mixed field in gel is easy, harder in tube but I would expect it to be there. I would therefore suggest checking very carefully for mixed field by tube (this may be an occasion to use a microscope to confirm mixed field if needed). Sounds like this is a good sample to use for mixed field training in your lab.

It would be really useful if you could tell us the ethnicity and age of the patient, and his medication regime. That having been said, I note that the antibody screen is positive, that his DAT is positive by both anti-IgG and anti-C3d, that the neat plasma contains an apparent anti-E and anti-c, but that the eluate contains an antibody that is, apparently, pan-reactive. Very often in these cases, the apparent antibody specificity in the neat plasma is a mimicking specificity, rather than a true specificity. In such cases, the apparent specificity in the neat plasma can be adsorbed out using red cells that are negative for the antigens of the apparent specificity; in this case R1R1. The true specificity of the antibody could be an anti-Rh17 or anti-Rh18. While I am not saying for a single second that the apparent specificities of anti-E and anti-c are not true specificities, it may be worth your while seeing if they can be adsorbed out using R1R1 red cells. However, as you suspect the presence of other antibodies, this should not be attempted until you have proved otherwise. This you can do, as you suggest, by alloadsorption of the neat plasma using two or three adsorption cell types. In answer to your last question, with regard to adsorption of the eluate, this was certainly a method we used in the Reference Laboratories of the NHSBT in the UK. It was usually used when the patient had a known pan-reactive autoantibody, but was requiring transfusions more frequently than previously, and/or when the expected rise in the haemoglobin concentration was not achieved. On some occasions, we were able to detect a de novo alloantibody in the eluate that we could not detect in either the neat plasma, or the adsorbed plasma, although this was not always the case, as transfusion in and of itself can sometimes stimulate the autoantibody to become more active (see Petz LD, Garratty G. Immune Hemolytic Anemias. 2nd edition, 2004, Churchill-Livingstone). Good luck with sorting it out, but this is a really interesting case. Thank you for posting it and, please, would you mind letting us know how you get on?

Guidelines in Australia are pretty similar to the UK guidelines as far as I can see. https://anzsbt.org.au/wp-content/uploads/2018/06/GuidelinesforTransfusionandImmunohaematologyLaboratoryPractice_1ed_Nov20_.pdf They require as well a second ABO typing.

The US has many different organizational blood suppliers. While some organizations are national like the American Rec Cross (ARC) there are many regional and even local organizations. In my experience, each center has their own screening policy, which is determined by their hospitals requirements. A region with a high sickle cell population may send all (or most) new African American donors for molecular testing, while other regions may only screen units when specificities are needed. So, when a blood center has an aggressive screening policy, or when they are looking for specific phenotype may affect the frequencies hospitals encounter. This explains Cliff’s and my experience described above. Also, the local donor population, and/or if (and when) the blood center imports units from a different region may impact the antigen frequencies hospitals encounter . As described by other posters above, I use the antigen frequencies to primarily determine the order in which to screen antigens and to manage expectations. For example, when I need to screen for R2R2 K- units there is an approximate expectation of 2%. I would therefore screen batches of 100 units; on one occasion I found zero units, on another 9 units with the norm being between 1 and 3 units. I am jealous screening for R2R2 K- units (or any Rh combo) would not be needed in the UK!!

Guidelines for pre‐transfusion compatibility procedures in blood transfusion laboratories - - 2013 - Transfusion Medicine - Wiley Online Library This is a link to the UK Guideline that talks about two samples being typed. All of the BSH Guidelines are evidence-based.

Pay now or pay later. I'd look at the volume of testing you plan to do on it, and the amount of hands on time required. We have a busy lab and two IH-1000. Most staff are comfortable running the two by themselves (and in this staffing environment we're all facing - that good ), some staff like assistance. Reagent cost - lease, reagent rental, outright purchase? Reliability Responsiveness of the company. Annual maintenance requirements? So much more to consider than the initial cost.

Hi! I am currently in the SBB program with Johns Hopkins Hospital as well as working there full time. I started in the Blood Bank in June of 2019 after completing my second degree in the CLS program at Louisiana State University. My previous career was as a chemist in various roles in the chemical manufacturing industries in Houston, TX. I came upon this forum while starting to brainstorm ideas for the big research project that is a part of my SBB program but ended up spending a couple of hours reading the various discussions. I look forward to hopefully being involved in future discussions!

I believe it's called "Computer Systems / Software / ISBT128". You may want to check there.

My Echo is 13 going on 14 years old. It's been very reliable, service has been good. I will be upgrading to a new instrument next year to avoid a surcharge on our contract because we are running such an elderly analyzer. I switched us from manual gel (which we used for about 8 years) because I was tired of weak antibody reactions that required PeG/tube to resolve. Solid phase has worked well with our patient population.

I agree with Ensis01. Sometimes gel can give a false positive - if there is a problem with the card/well or sample (bit of fibrin, etc) - which is resolved upon repeat and/or tube testing. Otherwise, yeah, if you can explain it = great, group specific (meeting all other policy, of course) If not = O. sandra

We extend our samples for 14 days for surgeries. We don't freeze, but we do antibody screening on day one, and on the day of the surgery make the patient sign a waiver stating they have not been transfused within the last 3 months (or been pregnant if a female). If the patient has an antibody, we require a fresh specimen within 72 hours of the surgery. If the patient has no antibody or a history of an antibody, we do electronic crossmatches. Since we do electronic crossmatches, the specimen itself is not used past day 1. BC

So sorry to hear this. My condolences.

Unless things have changed, I would consider the length of time from issue to completion of the transfusion more important than the time from issue to start. I'm assuming that a unit still has to have the transfusion completed within 4 hours. As for start time, that was initially instituted for returned units to be placed back in the refrigerator for reissue and as stated above 30 minutes is way too long. The 30 minute rule was instituted when blood was issued as whole blood in glass bottles and I doubt in anyone currently following this website ever saw that, me included! Time to drag a few nursing protocols into the 21st century!

If you set a time, such as less than 30 minutes, and they start the transfusion at 30 minutes, you can be cited by Joint Commission or FDA if they do a trace of that unit - unless there is a deviation from policy report on file. The 30 minute start time may be in the nursing policy, but when a tracer is performed, the deviation will fall back on the transfusion service to correct. Although we did ask that the nurses do the preparation before picking up the unit, there would be a phone call saying the start of the transfusion was delayed for some reason. (IV infiltrated while picking up blood is one I remember). When we started taking temperatures of returned units, we learned they were usually only acceptable to be returned for 15-20 minutes, depending on how they were handled after leaving the Blood Bank. After much debate, we changed the policy to start the transfusion as soon as possible with the emphasis on completing the transfusion within four hours of leaving the Blood Bank. We did require them to return the unit to the Blood Bank immediately if, for some reason, the transfusion were cancelled.

We use started within 15 minutes of release. Our experience is that after 15 minutes, rbc temps are too high to return to inventory. We do the same as far as if Nursing wants to return but will continue the infusion as soon as they fix "whatever",i.e., keep the unit on the floor.

That is not unique to north of the border

I just answered this question. My Score PASS  

I don't disagree Cliff. In Canada, it is a little different and it totally comes down to initial cost.

In some plasma components, it would undoubtedly be residual D positive red cells, as long as the component has not been frozen, as the freezing and thawing process would disrupt the structure of the membrane (although some people have theorised that the D antigen on disrupted red cell membranes may still cause sensitisation [I don't believe it]). However, once anti-D has been produced by a person, it takes minute amounts of D positive red cells to cause a strong secondary production (see around and about slide 60 of the attached lecture - which I know is about HDFN, but the sensitisation is the same). In Depth Lecture on Alloimmune Haemolytic Disease of the Foetus and Newborn HDFN.pptx

Yes. John Staley is correct

Thanks, Sandra. As I'm sure you knew, I am aware of the answer - no way, no how are blood suppliers going to "discard" ~10% of their product. But I think it's important to consider the consequences of some of the now routine testing algorithms. No testing mean results are unknown, but once one has information, one may be required to take action. Many transfusion protocols for chronic users involve Rh (C/E) and K matching - there's another batch of donors whose (partial) phenotype is known and considered to be quite immunogenic. It goes on. I do find it interesting that your system "hides" the K+ status, but openly prints the K- attribute on the label. Another thought: If the K type of all of the patients were known, they could get the K+ units. The antigen frequencies should match up.

having been a manual gel user for years I am switching to solid phase in the next few weeks (ECHO 2.0). I like the fact that it's pretty much hands off once on the instrument. I wanted to get away from gel as I've experienced many of the same discrepancies as with tubes. I expect this will have its own vagaries however it is a step up for my staff. Also the price was right for a refurbished unit.

In my opinion, you can run an antibody screen on the last wash instead of a full panel. Of course if the screen is positive, you'd want to run a full panel. I have never known the last wash screen to be positive.

I tend to work them the way "galvania" works them too. I just start with the high frequency antigens and work down to the low frequency ones. That is the way we screen too - eliminate the high frequency antigens and screen only the negative units for the lower frequencies as you get to each antigen. (mostly we just call our distribution center (Vitalant, El Paso) for units like that - they are doing an outstanding job getting units for the "messy" patients!!)

We have yet to see a patient on daratumamab who has made an anti-K antibody after years of transfusing red cells without regard to K antigen status. We use cord red cells in an antibody screen to rule out significant antibodies to allogeneic red cells (they are CD38 negative) as our method of dealing with this issue of pan-reactivity from daratumumab. I know this practice isn't allowed in the UK due to the over the top regulations that followed the infant parts kerfuffle. We detect plenty of anti-K's, just NOT in patients receiving anti-B cell therapies. In fact, I cannot recall a single new red cell alloantibody in myeloma or lymphoma patients receiving daratumumaub, rituximab, etc. No B cells equals dramatically reduced risk of alloimmunization, so you may be worrying about something that is pretty unlikely to happen. Just another approach.

There is a difference, I believe, between not being able to rule out an antibody in the context that it may be there, the answer no you state above, and not being able to rule out due to the method limitations (DTT). The DTT method limitations result in K neg units being given but once the DARA effects wears off a different, more appropriate (and better) method is used so anti-K can be ruled out and the K neg requirement dropped.

It depends upon the instructions that come with the reagent.

It makes sense to have a K neg policy while the patient is on anti-CD38 therapy, i.e. K neg units are given because DTT meant Kell antibodies could not be ruled out. Once anti-CD38 therapy is finished and if the patient never had anti-K and you can rule it out I see no reason to keep giving K neg units.

We do not unless the patient has Anti-K. Darzalex is just a transient interfering substance. If there is no DTT neutralization required and no antibody detected, it is not necessary. Plus, I don't see how I can charge for the antigen typing in that scenario. I think that risks fraudulent billing.

As David said there isn't a BB standard for time frame a transfusion needs to be started but for some reason this time frame is in the nursing policy, theirs is 20 minutes. Where they got this information I don't know. Anyway if blood is sent to the floor and it isn't going to be started in 20 minutes and the floor asked calls the BB (before they actually return it) we tell them if they are going to transfuse and it is will be completed within the 4 hours that it was issued to the floor keep it, otherwise it will be discarded (if temp is greater than 10 degrees)

There is no standard that requires a transfusion to be started within a certain time frame from release. the only timing that is critical is that the unit needs to be complete within 4 hours of release.

Yikes, can't imagine. We issue about 25k red cells a year. I have no idea where we'd keep the returns. We save a segment.

Our only difference was that we cut off 2 segments. We stopped getting bags back over 25 years ago. Hated the mess and getting them back served no real purpose.

We don't have bags returned to us. We take off 2 segments when we retype the units and save for a month, 1 week in each bag. It's easy to find by when it was retyped in the computer and there are only four small bags to check for the correct date.

If we are giving out blood tagged for a specific patient they are expected to do 2 person ID and they do it without complaint. It's very quick, but it's done. Anesthesia is very good about participating in the process if they are present. We do skip the FinalCheck locks for mass transfusion protocol, so there is one step in our normal process that is skipped. If at all possible we are hand delivering the blood to the patient location. (3 techs on during the evenings and 2 techs on at night to cover the entire lab, but they will call in help if they think they need it.) If we are sending blood to ER for more than one patient, we will post someone in the ER, outside the door to the treatment room, to ensure that blood is going to the correct patient. On evenings and nights that will be someone who has been called in to help. It might be our medical director - he's very good about coming in to make sure that everything is going well. He even answers the phone. (Yes, I do know how lucky we are to have that kind of support!)

This may shock anyone using Meditech TAR at their hospital but we have successfully implemented TAR in ED and OR (i.e. anesthesiologists) this year !

I think our pneumatic tube might be a her. If it were a him, it would never ask for directions before it goes anywhere.

I am going to be EXTREMELY controversial here, but I really don't understand why, if the cross-match is compatible, anyone would bother to type for the Cw antigen. I would be happy if someone could direct me to a RELIABLE paper that has shown anti-Cw to be clinically significant as far as an acute or delayed haemolytic transfusion reaction is concerned. I am aware of one paper in which it was claimed that anti-Cw caused hydrops in a pregnancy, but, for reasons I have given before, I do not regard this paper as reliable. The same goes for an anti-M that is not proven to work at strictly 37oC, and many other specificities. One only has to read the three editions of the FactsBook to see that there are numerous antibody specificities that are absolutely benign (unless your name is Lyndall Molthan - see Issitt PD. Applied Blood Group Serology. 3rd edition, 1985, Montgomery Scientific Publications, page 433. Anyone who cannot get hold of this is welcome to read my signed edition, but you'll have to give me £1 million as security, so that I get it back!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Sorry Eagle Eye, and I KNOW that this sounds terribly egocentric, but I don't bother with working things out like this any more. After a while, you sort of "remember", and you sort of "know" how common or how rare a particular combination will be, and you just go from there.

It is with enormous sadness that I have to tell you that, having just arrived back from a short break, I have been informed of the death of Prof. Dave Anstee - one of the greats of the world of Blood Transfusion and Blood Group Serology. I am devastated.

Thanks for the update, and very sorry to hear this.