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An excellent discussion point. I think many others have similar questions and concerns. The have been several other threads on this forum with similar subject matter. As an Old Fart, I feel obliged to spout some (un-referenced) history. Most of the original work on clinical significance of antibodies in pregnancies was done in the absence of potentiators and definitely before the use of (semi)automated test systems. I think it was a "saline-IAT" using 22% albumin (BSA) as a diluent. Most of those antibodies were anti-D, for obvious reasons. There's not much out there in the literature in

Quite right John. In the UK, we ALWAYS test the previous sample with the latest sample (unless there is a legitimate reason why the previous sample is not available - sample too small, freezer broke down, Malcolm dropped it, etc!). This test is essential in my book, as antigen expression can vary hugely from one donor to another, resulting in either a falsely high titre or a falsely low titre - and either can be dangerous.

My experience is that the BB reports out the antibody identification. Never the reactivity! If a titer is ordered the only thing reported is the titer or “too weak to titer”. As the rise in titer is the most relevant result, consistency in method and technique is very important, both within your hospital system and the reference lab you use. Physicians are interested in your results not the process. Keep that simple. If they have questions your Medical Director can enlighten them.

Just a thought, I have not seen anyone mention in this thread, testing the current sample in parallel with the previous sample. We would start with the very first sample and freeze what was left after the initial titration. We would then thaw and run it in parallel with the next sample. This was an attempt to mitigate the, hopefully, minor differences in technique between techs and give us an accurate picture of any increase in antibody levels.

Cannot post the entire article due to copyright restrictions, but most institutions have access to NEJM through their library. If not, shoot me an email at neil_blumberg@urmc.rochester.edu and I'll send along the .pdf. If you are transfusing 40-60 platelets a day, giving ABO identical to group O and A individuals should be relatively easy. When patients are changing ABO blood group it becomes more difficult. We avoid transfusion ABO antigen and/or antibody that is incompatible with either original recipient type or donor type. Usually means washed group O red cells and platelets. That

While reading one of the threads today it got me thinking, does the University of Michigan still hold their annual Blood Bank Symposium the last of May or early June? It's been a very long time since I was able to attend but for quite some time I was able to convince the powers to be to allow me to attend every other year. Every year was a little too much to hope for. I learned a great deal, met many terrific people, and made a number of friends. I was able to meet and learn from a few of the greats in the blood bank world at the time. I certainly hope it has carried on and is still avai

Research letter in NEJM describes our findings. https://www.nejm.org/doi/full/10.1056/NEJMc2034764?fbclid=IwAR1BQRvpaHBAMDaHxCPY07xBjPQHlIHoJCOmpjoT_pBNvQsV7pzzDVdLYaY Table 1. HLA-Matched Platelets as a Percentage of All Platelet Transfusions, According to the Initiation of Other Protocols.* Protocol and Timing of Initiation No. of Years HLA-Matched Platelets Difference from Previous Period (95% CI) median % (IQR) percentage po

Once clinicians understand that ABO mismatched platelets not only do not provide hemostasis, but make bleeding more likely/worse, they will be less willing to accept infusion of ABO mismatched antibody/antigen. Once blood transfusion services realize that infusing ABO mismatched platelets increases utilization by two fold, they will be more interested in making the effort to give ABO identical or remove incompatible plasma by washing. Doing the right thing for patients is never the wrong answer to the question. Our current practices are convenient for us and minimize waste. We need to prior

To answer your first question - Yes, we have seen several antibodies On ECHO/LUMINA) that we can not see in the titers (saline only / 2 fold dilutions/ 30 min inc). Especially Anti-E. I once talked to a reference Lab about titers (we had an anti-G - such fun) and they felt it was most important to try and replicate the In-Vivo condition in the mother for clinical significance - therefore - no enhancement medias and heterozygous test cells, where possible. That is what we have done since and we just have the Med Director answer any questions they might have (after a through briefing, o

Tubes without enhancement is what I have always used. I don't care for the CAP method as it is actually a 1:3 serial dilution vs the 1:2 which has classically been used. (maybe it's ok because the "new" method is read microscopically vs macro read for the classic method).

I get what you're saying, but remember, with the antibody screen and panel you are using sensitive methods to detect the presence (and i.d.) of a clinically significant antibody. The titer is merely measuring the "concentration," if you will, of the antibody in solution. They are really two unrelated attributes. We use gel method for screens and i.d., but perform the tube method titer in saline using the CAP recommended Uniform Method.

The prediluted cells from Ortho contain the antibiotic nitrofurantoin as I recall. I think that contributes to why they are to be kept in the dark as that drug is always dispensed in a brown bottle. Patients make antibodies to the antibiotic and thus react in the prediluted cells. Diluent 2 lacks preservatives because we can't store the suspensions over 24 hours so 3% cells suspended in it don't react with antibodies to the antibiotic because the antibiotic isn't present. In my experience, the antibiotic doesn't seem to wash off of the cells but rather adheres to them. What you are doing

It simply means that the P1 antigen is particularly strongly expressed on these red cell samples. Therefore, if you come across a weak anti-P1, it may apparently react with these particular red cell samples, whilst apparently not with, for example, the third red cell sample shown in your antigram. Although not identical to dosage, per se, it is fairly synonymous with dosage at a phenotypical level. The strength of the expression of the P1 antigen is an inherited trait.

Clarifying question - Is it Friday afternoon or Monday morning?

Well labgirl153, there was a little paper written in 1945 by Coombs et al (Coombs RRA, Mourant AE, Race RR. Detection of weak and “incomplete” Rh agglutinins. Lancet 1945; ii: 15-16) that rather contradicts your theory of this SOP being "bogus". I think that you should remember that, before we had enhancement, this was the ONLY indirect antiglobulin technique that was available and that, although a few patients may have been "lost" due to incubation period, none were "lost" due to antibodies not being detected, as long as the test was performed correctly. If you do not acknowledge,remember

Depends on the beer . My Belhaven Black better not be ice cold.

OK i dont really understand this, but i asked for more specifics - and our backup computers are evidently attached to the network but in a weird limited fashion where they get a solitary incoming dump every four hours, of BB data, but otherwise do not receive network activity, and have no "outgoing" channel. when we were hacked, one was due for a dump and got hacked, the other was instantly quarantined off-line and so had almost all (except the last few hours worth) of BB data. also was just told it is also now stashed in some quarantined part of the cloud? this is waaaay over my head in

Thanks all - that's what I suspected. My patient's antibody is still reacting fairly strong in solid phase, so I'm relying on crossmatch for Cob donors. Think I"ll freeze some plasma for screening purposes in case his titer drops.

Disciplinary action over product wastage sounds like it is perhaps well intentioned but ignorant bureaucrats, not health care workers running the show. That's a big part of the problem in many institutions these days. We are fortunate in that the senior decision makers in our hospital are all physicians, nurses, etc., including the CEO, CMO, COO. Washing your hands before delivering babies turns out to be inconvenient but a better idea. Universal leukoreduction and avoiding infusion of ABO incompatible antigen and antibody are also better ideas than what we have done for decades or lon

Agreed to all the above; as you say you have implemented a policy that prioritizes clinical benefit over inventory control and waste reduction, which the hospital (physicians, Med Techs and bean counters) follow. My experience, however, is disciplinary action taken over product wastage. So unless a hospital implements a policy similar to the one you outline, which the Med Techs can follow, giving only ABO specific platelets will be problematic.

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.

We are a large registered facility. We received the request last week, and only have two weeks to comply. We also have a Donor Center. We will need all of those two weeks to gather the documents they requested. There is a lot lost in doing it this way. I have been directly involved in our department's inspections for over 20 years. I enjoy interacting with the inspectors, ask a lot of questions, and learn a lot. I do hope there is an onsite portion to the inspection.

The problem is that the NHSBT "scores" for the P1 expression strength is subjective, rather than objective, and so it depends upon who does the "scoring" as to how accurate, and, indeed, how precise the scoring may be (but it does give an idea).

I retired recently so I do not have access to the product insert but I do remember that cells stored in LISS for longer periods can give some false positive reactions. Also, cold antibodies are enhanced by LISS so by diluted your 3% screen cells there is less time in LISS so less chance of false positives that can be experienced with older cells stored in LISS and also less chance of picking up a non specific cold antibody.

LOL! We would send it to our reference lab! We have other things to do here... Scott

Our inpatient consents are also good for the entire admission. I believe that outpatient consents are good for 6 months or the length of a care plan, whichever comes first.

Our inpatient consents are good for the length of that admission and our outpatient consents are good for a year. We've never had any issues, but you might check your specific state rules.

I should, perhaps, also mention that the Red Cell Reference Laboratory of the WHO INTERNATIONAL Blood Group Reference Laboraotory (the IBGRL) t NHSBT-Filton Centre, Bristol, England, uses tube IAT almost exclusively, and they aren't bad at serology!!!!!!!!

Hi labgirl153, I won't weigh in with an opinion or facts regarding your question, I will ask that you reconsider your harsh tone toward some very smart people who are offering advice and their many years of experience. People here are not paid for the time they spend helping others, and responses such as your will lessen their willingness to continue. Remember, You can catch more flies with honey than with vinegar.

I had a corporate transfusion service medical director who was uncomfortable with the term "CMV safe" so we were required to use the phrase "CMV risk reduced"! I know it doesn't add anything to the discussion but when I read Ann's post the memory made me smile at the lengths some folks would go.

The suggestion I got was to make it a routine maintenance task. Connect your backup computer once a week to the network and load the backup file. I talked with our IT people and they said they could set that up so it was a matter of accessing a file on a server and downloading it. The hows and whys are all magic to me, but the IT analyst I talked to wasn't at all concerned about any difficulty doing it. Then, of course, the computer has to be totally disconnected from the network or you risk exposure to bugs and hackers. WiFi shut off and/or cable disconnected.

Thank you @AMcCord. That’s very good information. I am fairly new to the hospital and I am just now discovering their culture. The entire hospital share one person for quality. And this person is also taking care of infectious control. We also do not have a BB medical director. Though, I am going to take your recommendation and approach lab director and hopefully he would stand his ground for patient safety. My next step would be reaching out to the quality person.

Thank you @Kathyang!! Nurses doing short cuts to get around the system is my biggest concern. With the short 3 months that I am in my current hospitals, I already have multiple proofs that nurses are doing short cuts (preprint label, scanning chart instead of waistbands…) and not closing the loop of verifying the patient before sending down the samples. I think I have built my case well citing standards and etc. But my lab director was holding onto the statement that as long as we have an electronic identification system, we do not require a second sample. My “argument” with her was what

We have always asked for another tube when a patient doesn't have history when using electronic ID. We know that the electronic ID is good but there are ways to trick it so they can san something besides the bracelet. I have used 3 different systems with electronic ID and nurses still try to get around using the proper scanning technique. We got support from our Medical Director and we just did it We also have a second person draw the tube, not the same nurse or phlebotomist.

We do, 'just because' ... it's easy to find K-Neg RBCs and one never knows if they are going to try it again so we don't want to deal with switching around. We have one patient who seems to be chronically infused with this stuff!

If you're up for a little more discussion (and a little entertainment ) may I suggest this thread, from 2012? Saline incubation...why is this SOP still allowed?

From my manager's "old school" approach that if a clinically significant antibody is present with a warm auto, it will react alone without enhancement media due to its supposed "high" titer. Similar to slsmith, we incorporate this approach when we have panagglutination in our more sensitive methodologies and are trying to "look through" these reactions. It's never our sole method or what we use to report, but just another arrow in the quiver of techniques.

We use it when working with a patient with a warm antibody that has had all significant antibodies ruled out by the reference lab. The gel screen is still performed each time to make sure reactions are not getting stronger or no longer demonstrating. Then the saline panel is performed. We also transfuse with phenotypical matched blood for Kell, C, E and c . This procedure is usually being performed on the frequent fliers that we know are only coming to our hospital. We also use it when a gel shows no pattern, all cells positive or negative and we have gone to PEG and all cells are positi

oh my goodness. You poor thing. You have really been through it. I admire you for your strength. You are very brave

The BioRad panel sheets only usually give + or 0 for P1 whereas NHSBT give numeric scores which is much more helpful when the antibody only reacts by IAT with strong examples. A cold panel helps with any ambiguity too. (and P1 type on the patient, but who stocks anti-P1 at a hospital?)

We removed and saved 2 segments from all unit when they are received in the blood bank. These are saved for 2 months in the case of a transfusion reaction investigation. Empty bags are only returned to the blood bank if there is a suspected transfusion reaction.

We stop the transfusion and initiate the transfusion reaction procedure. And until the workup is complete (minus any micro), the patient is unable to receive any other products. Normally it is just something with the donor plasma and Benadryl should cover and propholactically thereafter prior to transfusion. Normally the physicians order Tylenol before the transfusions, so adding Benadryl is not an issue.

We tell our clinicians to do exactly that, yes. Likely it won't turn into an anaphylactic event, but it could, so STOP and initiate a transfusion workup. Give benadryl and watch the patient. For future transfusions, pre-treat with benadryl - even though it's likely a response to that one specific donor's plasma proteins, and a bag from a different donor may not provoke a reaction.

I just had to share this story...When I worked in a large teaching hospital we had a team of Transfusion Nurses who were responsible for drawing most samples and administering the transfusions. Occasionally, however, physicians (or interns/residents) would draw the samples. One afternoon we received an unlabeled sample drawn by a physician via courier. We contacted the physician and informed him a new sample would have to be drawn. He said he would come to the transfusion service and label it right away. We told him that was unacceptable, however, he insisted. While he was on his way, we put t

I have even gone so far as to tell the nurse taking care of the patient that when they learned the patient's name and not the room number to give me a call back and we will discuss the patient at that time.

I just want to mention the saline titration procedures that are in the Technical Manual and that the CAP promotes as their preferred procedure. Their supporting paper will pretty clearly show that saline technique can detect antibodies (see the CAP website). I have seen many antibodies react when titrated by a saline technique.

labgirl153, step back a minute and re-read this sentence: now you don't really expect me to adhere to a single paper from immunohematology's ancient priesthood to hold water do you? You have asked the folks on this board to comment. If you choose not to "agree" with someone that's fine but you are coming across a little snipp-ey for lack of a better description. rravikin is not suggesting more work for you, I read his suggestion as just that, a suggestion. We have lots of tools on our antibody ID toolbelt and saline enhancement is just one of them. Think about it, there is no enhancement m

Quote: "We will sometimes use no enhancement media to avoid warm autos (and colds), using 3-4 drops serum, a 60 minute incubation,..." We also use this technique as the only way we can attempt to see under Solid Phase/PEG warm autoimmunes here. We have used the procedure for years and can routinely see the known alloantibodies, if still present. Since our Reference Lab (I will put in a plug here for the finest reference lab I have worked with - Gulf Coast Regional in Houston, TX - fast, accurate and nice to work with) is a plane flight away, sometimes we have to do the best we can with what

I think I'll pass on joining this discussion since I am old, retired and can't possibly contribute, but thanks for asking.

We are a CAP accredited lab and 2x year we compare all our testing methods. We compare gel, LISS, PEG, saline techniques. All methods have detected all clinically significant antibodies. R1R2