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If the unit if leukoreduced, as all red cell transfusions should be, there is no need for CMV negative in my view.

The three months was chosen following a paper written by Laine EP, Leger RM, Arndt PA, Calhoun L, Garratty G, Petz LD. (In vitro studies of the impact of transfusion on the detection of alloantibodies after autoadsorption. Transfusion 2000; 40 1384-1387. DOI: 10.1046/j.1537-2995.2000.40111384.x.) that showed that red cells that had been transfused (or entered the circulation via a feto-maternal haemorrhage could adsorb out weak alloantibodies for up to three months in a patient with AIHA. This in vivo adsorption would, of course, also apply to individuals who did not have AIHA, but could lead to a secondary stimulation, leading to a stronger antibody (higher titre and higher concentration per mL of plasma), if the alloantibody was "missed" in the antibody screen and/or cross-match, particularly as it is unlikely that the full phenotype of the transfused (or foetal) red cells would be known.

There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong. See below for the reasoning and published data. We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data. BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1 Letters Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data. In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5 We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients, such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply. Competing interests: None declared. 1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250 2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995 3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A. 4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246 5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035 Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions LETTERS

We do not routinely transfuse neonates (have not done one here in 30 or so years). We would give the freshest O= we have; irradiated if we have one. We are 3 hrs from our blood supplier. Chances are the infant will be transfused before we could receive appropriate products.

Over my many years I have come to realize that inertia is the most powerful, driving force in the universe and the most difficult to over come!!!

I agree with David and his comments above. We transfuse neonates very rarely as well. Considering you are a small rural health center and will not be doing this routinely, you just have to do the best you can in an emergent situation. We do keep neonatal syringe sets and most of them outdate.

Here the Medical Director or designee is the one responsible for contacting the patient's physician. If the patient's physician refuses to contact the patient, our Medical Director or designee will end up having to do it.

The timing for fresh samples is somewhat different in the UK than in, for example, the USA. The timings, and the reasons for these timings, are set out in paragraph 3.7 of the BCSH Guideline "Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories" (written by Claire Milkins, Jenny Berryman, Carol Cantwell, Chris Elliott, Richard Haggas, Joan Jones, Megan Rowley, Mark Williams and Nay Win, for, and on behalf of the BCSH, and published in Transfusion Medicine 2013; 23: 3-35. doi: 10.1111/j.1365-3148.2012.01199.x), with the Key Recommendation of this paragraph being, "Serological studies should be performed using blood collected no more than 3 days in advance of the actual transfusion when the patient has been transfused or pregnant within the preceding 3 months." As I understand it, this timing was based on the work originally carried out by Professor Patrick Mollison many years ago, who found that a new specificity of an alloantibody, or a nascent antibody that has become undetectable by normal serological techniques, can appear (or reappear) in the plasma of an individual within three days, after stimulation. The problem is that not all patients know whether or not, or when, they have been transfused, or may deny it for religious reasons (I once cross-matched for a patient who had been a life-long Jehovah's Witness, who had an anti-Fya in his plasma that had a titre well in excess of 128). I hope that helps.

This is a clinical call that we make between the senior medical technical staff present and the attending physician. We routinely switch male patients, and older females who are Rh negative to Rh positive red cells when transfusion rate is significant and supply constrained. No policy. Just a clinical decision, which we communicate to the treating team. Typically a liver transplant that has gone badly, an exsanguinating trauma patient and similar situations.

We use either ABO identical or washed O red cells. Usually volume reduced so the hematocrit is around 70-80% either by centrifugation or washing with Plasmalyte. We have data that saline washing is likely associated with more hemolysis and metabolic acidosis. Leukoreduced and <21 days old. We prefer not to use the very short storage red cells (<7 days) as there is evidence they are more dangerous from randomized trials, albeit in mostly adult patients. We do not CMV test or test for hemoglobin S, except for exchange transfusions. No evidence that hemoglobin S trait is a problem for transfusion in any situation, but particularly for smaller volume transfusions. We do irradiate for newborns since immunodeficiencies, while very rare, are often not diagnosed until later in infancy or early childhood.

Does acquiring more good blood banking staff count?

Have you considered that your patient could be a particularly low-grade weak D, a partial D of some kind (such as an RoHar), which would explain the anti-D in the eluate as a result of the RhoGam, or that what you are detecting in the eluate is not an anti-D, but is an anti-LW? I also assume that the last wash is totally negative? Sorry to ask this.

Sickle trait cells do not sickle under physiologic conditions compatible with life. Purely a theoretical construct. Oxygen transport is also normal under physiologic conditions compatible with life. The evidence that sickle trait cells present any risks to any patient through transfusion is exactly zero. Patients with sickle trait rarely, if ever, have any problems attributable to sickle trait. The epidemiologic evidence is likewise weak, if not zero.

I agree. You do the best you can with what you have. Unless your blood supplier or a large neighbor who can transfer product is close by, you are not going to be able to ship in product in time. It is cost prohibitive for us to stock product routinely for an event that occurs very infrequently (and your blood supplier may not be very enthused about the constant rotation of product). We are 150+ beds, have a NICU, and are one of the 'large' hospitals in our rural area, but still transfer our critical neonates/kids to Children's 150 miles away. We only transfuse babies and small children 1 to 3 times over an average year. Our facility sees quite a few Onc patients, so I do stock a small inventory of irradiated products including 2 O neg Irrad on top of our normal O neg stock (if we can get O neg - fun times!). If we have time to crossmatch, we provide the freshest type specific unit (if we know mom's type) on the shelf, irradiated if requested and we have it in stock. If not, we provide the freshest O neg unit on the shelf, irradiated if requested and available. Children's gives LR as CMV neg equivalent, so that's the policy we follow. I don't stock syringes because we would outdate almost all of them and our software is not set up to split/label units. (It would be very rare for us to even have the possibility of pulling blood off that unit a second time, so not worth setting up.) We hand over the entire unit and the pediatrician/nurses pull what they need for transfusion in the 4 hours after issue.

There are several layers to this question. First, you will need a fresh O negative, CMV-, irradiated prbc available rather quickly. We are not small but we only transfuse neonates about 3-4 times/year yet we receive a fresh unit every Monday to use for emergency transfusions. If it is non emergent (say for iatrogenic anemia), then we order from our supplier a fresh unit with satellite bags sterile docked so we can continue to use that unit for future transfusions on that baby. The goal here is to limit donor exposure. You may not need to worry about that if you do not have a high level NICU. Are you aliquoting the unit into syringes? You will need a procedure and supplies for that. You need to meet with your Neonatologist and work out your logistics. Those are just a few things to think about. I assume you already have policies and procedures in place for this.

We have a contract to provide blood to our air ambulances, but they charge the patient if they transfuse it (well, it's wrapped into their total charges for the flight, but we don't charge the patient). If the patient comes to us, we do the XM like we would for our own UNXM units but if the patient is transported elsewhere, we maintain final disposition of the unit in our computer but don't do the XM (yes, we give the patient a fake account in the BB computer using a specific format). It is just easier for us to maintain the record of the unit's final disposition for if there is a market withdrawal etc. We would notify the air transport company to do the patient or next of kin notifications if that were ever needed. It hasn't happened yet so it isn't a big problem.

Not only is it quicker to issue 2-4 LTOWB, it is also easier for rapid infusion. The products are supposed to be infused through blood warmers rapidly. This is important to avoid that "lethal triad" of hypothermia, coagulopathy, and acidosis in traumatic bleeds. Whole blood has been shown in studies to be more effective than components in these cases as they can be given quicker and through only one iv access. With 4/4/1, you need at least two lines and possibly more than one rapid infusion pump.

We would rarely perform an eluate on the baby's red cells unless there are clinical (as opposed to laboratory) signs of HDFN. In other words, an elution is not considered to be a "reflex test", just because the baby has a positive DAT.

If you have any, you could try D Negative Cord or Neonatal red cells, which express the LW antigen comparatively strongly (certainly compared with adult D Negative red cells).

While the Ogata-Matuhasi phenomenon has been recognised since the early 1960's, it is, that notwithstanding, a very rare phenomenon to actually come across in practice. With all due respect to you Bet'naSBB, if you "see this quite a bit", I would be a bit worried as to why.

@rmilford, have you considered the DCLS program at UTMB? Since you are considering the SBB, which I think is worth the knowledge alone, you may find that the DCLS program will do the same and more, giving you a terminal degree. I anticipate the role of DCLS will become important in healthcare in the near future. It also opens up more possibilities outside traditional lab roles, including teaching higher education. Just another thought.

Getting your SBB is great knowledge to have, and I agree with Cliff that it will open more doors for you to do other things. Having worked in large busy trauma center BB's for 17 years now, I can tell you that my SBB knowledge rarely comes into play in a hospital BB, unless you have ALL the things (complex antibodies, washing/irradiating product, neonatal population, ref lab for system hospitals etc). If you have goals of Ref Lab or a private company, many of them require an SBB. You can also get in with a teaching program with an SBB easier than without. I've heard many hospital labs would like to have their admin directors be blood bankers with an SBB, as it brings a quality eye that other candidates don't have, but it seems rare to find those people because so few of us want to do that job! As far as helping you run your blood bank, it likely won't be that beneficial, as most of the curriculum is a deep dive into antibody qualities and rare things, but there is some info on supervisory duties and such. I graduated from LifeShare's SBB online program in 2019, after having worked in the BB for 10+ years. I personally liked the online program, as I already was the supervisor of the BB at the time, had two small kids and was not able to move across country to attend a program in person. LifeShare and UTMB share their curriculum, and an SBB from LifeShare is eligible to go on to the Masters in Trans. Med from UTMB should you wish to do that. Katrina Billingsley is the director of the program at LifeShare, and she is fabulous; would highly recommend her program.

I expect that you will see an increase in your knowledge base. No matter how busy a BB you work in, you may not get the minutiae you need to pass the SBB. Good luck.

Phew, I am certain I do not deserve those kind words, and nor am I sure that I can live up to them, but I will do my best to explain Kea. The first thing to say is that not everyone who is K Negative, as your father must be, otherwise he would be unable to make anti-K (which is what they mean by saying he has made anti-Kell - VERY bad nomenclature on their behalf!). Except in certain, rare, pathological conditions, one does not produce an antibody against an antigen expressed on one's own red cells. I suppose really, I should start by explaining some terms. An antigen (in this case, I am talking about something expressed on the red cells - they can also be expressed on white cells, platelets and other tissues within the body - but that will complicate things more than is required, so I will stick to red cells) is a structure on the surface of the red cell (usually either a protein or sugar) that, if these red cells are transfused to another individual who does not express the same antigen on his or her red cells, can stimulate the recipient's immune system to produce a specific antibody directed against this antigen. This antibody can lead to the destruction of the transfused red cells, should such antigen positive red cells be transfused to the same individual a second or subsequent time; so, in this case, if K Positive red cells are transfused to a K Negative individual, the recipient may produce an anti-K as a result, and if K Positive blood is transfused to this individual a second time (after a few weeks or months), those K Positive red cells may be destroyed in what is called a haemolytic transfusion reaction (please excuse my English spelling!). Another way in which such an antibody may be produced is if a woman is, for example, K Negative, and her baby is K Positive (the K gene would have to be inherited from the biological father for the baby/foetus to express the antigen on its red cells). Some antibodies are produced "naturally", without stimulation with red cells. Two things are important to say here. Firstly, an antibody is NOT produced by everyone when they are transfused with red cells that do express an antigen that the recipient does not express (or the pregnant woman does not possess -despite the fact that in almost all pregnancies there is a small bleed from the foetus into the maternal blood system).; the production of an antibody is by no means automatic. Secondly, the transfusion of antigen positive blood to someone who has made such an antibody does NOT necessarily mean that they will have a haemolytic transfusion reaction (certainly not one that is clinically significant). So, getting back to your family, your father MUST be (or have been) K Negative, and MUST have been transfused with K Positive blood at some point during his life (he, fairly obviously, could not have been pregnant with a K Positive foetus - and, if he was, I want to be his manager!!!!!!!!!!!). Now, for an antigen to be expressed on an individual's red cells, they have to have inherited a gene, either from their mother or their father (or both) that encodes for that particular antigen (genes are inherited, but antigens cannot be inherited - they are the result of inherited genes). Antibodies, on the other hand, which are found (normally) in the plasma (the "watery" part of the blood) once they have been stimulated CANNOT be as a result of inheritance (except very loosely, in that some, very rare individuals, never seem to produce antibodies, however many times their immune system is "challenged" by a "foreign antigen"). This means that, unless your elder sister is, as is likely, K Negative and then received either a K Positive transfusion, or was pregnant with a K Positive foetus, she is unlikely to have produced an anti-K. Similarly, if, as is likely, your brother is K Negative, he is most unlikely to have anti-K in his plasma, unless, at some point during his life, he was transfused with K Positive blood. The fact that antibodies are NOT inherited, it is highly UNLIKELY that your nieces and nephews will have anti-K in their circulation. The McLeod phenotype is very, very unlikely, as is the McLeod Syndrome. They can both be inherited but would result in antibodies of different specificities than anti-K but may well also result in certain other pathological symptoms, so I really wouldn't worry about that. Sorry, I have gone on a bit, and I hope this helps, but will attempt to attach a PowerPoint lecture that may explain things further, should you be so obsessed as to read it! If this is not what you wanted, I would suggest you ask another member of this group, named "Danny", who knows more about the subject than I ever will. In Depth Lecture on the Kell and Kx Blood Group Systems.pptx

When my supplier has a dearth of O Negs, if I get an O Neg patient who looks like they may be a big user, I contact the Medical Director. I also talk w the provider. Depending on my inventory I may ask to immediately switch to Rh+ units. We only stock 6u (overstock hosp); we have to have 2 for females of child bearing potential. A big user can totally deplete all my O's.

There is an AABB standard that your facility has to have a policy on how many out of group PLASMA transfusions are allowed. This very broadly encompasses LTOWB. It's 5.15.4. That said, our level 1 adult center will give 4u of LTOWB once MTP is activated, then switch to component therapy, of which our packs consist of 4 reds and 4 type A liquid plasma. Obviously, we end up transfusing incompatible plasma on occasion to B and AB patients with our normal process. Once we have a patient type we switch to type compatible plasma of course. Our policies state this, but there is no maximum number we have defined of how many units we'll give, as sometimes we don't ever get a sample until much later than we'd like, which means we're giving A plasma for a bit. We capped our LTOWB at 4 units, mostly due to inventory constraint when we started this program, but also to ensure we weren't overloading patients with too much O plasma if they weren't type O! Our supplier has a low titer cut off of 256. I track all of the patients who have gotten our WB, including their native blood type, and we are monitoring for issues, but have had none yet. I have heard of programs that will give up to 8 units of LTOWB per patient.

With respect to RBCs. If the patient has unidentified antibodies (as the title states) then NO. If you have identified the antibodies but can not confirm the patient’s antigens (as your question states) and the AHG crossmatch is compatible with units negative for the antigens that the patient has antibodies to then yes, though there are some/many possible caveats. Hope that is not too convoluted. It would help us if you give more details. Can you please explain what you mean by filters as in this context it is a little concerning to me.

What eluate kit do you use? If you use one with a "working wash" - try repeating your eluate, washing with normal saline instead...........usually takes care of it. We see this quite a bit - especially with Rh's and K's. Our Medical Director refers to it as the "Ogata Phenomenon" https://www.bbguy.org/education/glossary/glm06/

How about a "Del" ? Fits the description perfectly. One the other hand, "twice in the last few days" is worrying. While not impossible, it's highly unlikely that a facility would encounter more than one of these anomalies (zebras) in such a short period. I assume Malcolm's question regarding the Last Wash is an allusion to some laboratory artifact - bad technique, bad reagents, etc.

Understood. There are many things laboratories do because they've "always done it". Those in the decision-making roles probably saw a "bad case" somewhere along the way and it stuck in their brains. I will concede that there are a smattering of cases of Lewis antibody-mediated transfusion issues to reference, but most workers consider them an insignificant nuisance.

@exlimey if a Lewis antibody is identified - we type the patient...... it's just how our protocols are written. The only time we would be required to provide Lewis antigen matched units would be if the antibody demonstrates hemolysis at AHG otherwise just XM compatible. Do I know why? not really - I've just been doing what I was told......for almost 35 years.

I just replaced mine last month. I used to use deionized water on the old one until I read this (taken directly from the Helmer manual):

Those are theoretical constructs. The data suggest fresh isn't best if there are more infections as there have been in randomized trials of fresh vs. average storage period. More study needed, but the data are more important than the dogma. Infection is the most common cause of morbidity and mortality in all hospital patients, including newborns.

Have an O neg, CPDA-1 or AS-3 irradiated unit (no mannitol) on hand and give it. The fresher the better. - Could maybe set up some sort of standing order with your supplier for 1 fresh O neg AS-3 every 10 days so that you can rotate the older O neg into regular inventory and keep 1 fresh set aside for the off chance you'll need one?????

We do the same as David, issue the freshest O NEG unit we have, irradiated if fresh. We issue the whole unit of pack cells and nursing staff remove desired quantity to infuse and airlift is generally on their way to take the baby to Children's hospital. We transfuse about once every 10 years or so.

When I worked in a hospital, we notified the patient directly on all lookbacks, and we also sent the patients PCP a courtesy letter. We found that the PCP rarely notified the patient, so we chose to make our lives easier and notify the patient ourselves.

The BB supervisor sent a certified packet to the physician on record. We included a letter documenting the transfusion, a copy of the current FDA requirements for notification, and a form for them to complete and return by a certain date with the notification information. The Medical Director’s name and phone number were in the letter as the contact person for the physician. The Medical Director was copied on this info in case he was called. If the completed form were not returned, the Medical Director called the physician. Every phone call, etc, was documented. There were problems, as mentioned above. We had hospitalists who only treated the patients in the hospital who might not work there anymore or did not feel responsible for follow-up. What if the patient went to rehab and never went home? If we could not reach an end point, we sent to risk management for resolution.

Precisely! Our current conundrum is a snarky Ortho attending who is insinuating that our blood supplier and my blood bank gave the patient "contaminated blood" and he shouldn't have to be the person to notify the patient. Snarkiest of the snark, and its clear there is little understanding of the risks of transfusion. My medical director wants to involve our Patient Safety and Quality folks or Risk/Legal, since this is an FDA requirement, and I think we'll have to take that route, if for nothing more than educating the physicians.

It will open more doors for you. Don't fret if you fail the first time or two, the majority of people do.

We accept them back and use them. We put Safe-T-Vue indicators on them, control the refrigerators at some hangars, validate their transport containers and have reviewed the procedures and documentation for storage at the other company's hangar.

Here is our titer worksheet. We do a lot of prenatal titers for our Maternal-Fetal Center (high risk pregnancies). TO-300F01 Antibody Titration Worksheet.docx

The only thing I am aware of is the collection of low volume units. 300-404mL WB collections with anticoagulant not adjusted - you can use the rbcs but no other components can be prepared. There are also low volume collections for autologous, where you may adjust the volume of anticoagulant based on the donor's weight. There is no defining statute regarding minimal volumes for transfusables that I am know of.

In the Library on here is a powerpoint that goes through the process. They don't get feedback but it is very step-by-step. I posted it years ago so searching in the files by my name might bring it up. Or it is in the most-downloaded section, it looks like.

Malcolm, my very 1st AABB inspection came about 2 months after taking the Blood Bank supervisor job. After it was over I contacted AABB and told them that I would never let that inspector in my facility again and if they tried to send her I would drop our AABB membership. YES, the inspection/inspector was really that bad and luckily I never had to carry through with my threats/promises.

We are the same. We get a fresh <7 day old unit shipped in weekly from our blood supplier, so there is always an option for a fresh unit. We don't transfuse a ton of neonates, but our policy is to provide freshest possible, CMV safe/leukoreduced and HgbS neg to all babies. Those who have a very low birthweight or other indications for irradiated products will also require irradiated. Since the unit we get weekly is irradiated, pretty much all babies get irradiated because it's the freshest we have. We aliquot units to a syringe or bag, but in emergencies we will send the whole unit to the NICU if they can't wait. Same for platelet units.

We are a 400ish bed hospital, but our NICU usually sends the really sick babies to nearby Children's Mercy. We do not irradiate on site. We would have to get them irradiated at the blood center and the docs usually don't want to wait. I'm just trying to get information to adjust my policies since we ALWAYS have to get it out when a request comes through. Do you aliquot the unit to a syringe or send the entire unit to the NICU?

Yes John, With higher dose anti-D immunoglobulin, the DAT of a D Positive baby is quite often positive. In the UK it is now quite common to give a dose of 1, 500 IU of anti-D immunoglobulin at 28 weeks of gestation and, as a result, many babies have a positive DAT, but I have never heard of clinically significant HDFN as a result, Physiological jaundice is also quite common in newborns, whether the mother was given anti-D immunoglobulin or not, and whether the baby is D Positive or D Negative.

I guess low titre anti-A and anti-B. We don't have any whole blood. The usual major haemorrhage pack provided is 4 red cells and 4 FFP for transfusion in 1:1 ratio. During the TT motorcycle road racing we keep a box of 2 O neg red cells and 2 group A FFP for immediate use. This hopefully gives us time to test a sample and issue group specific if further units are required.

Thanks everyone for your replies and comments. Yes to Malcolm, the last wash was negative. The Elution kit we use is from Gamma, the Elu-kit. One correction though, I only had one eluate recover the anti-D, the other one was a warm auto. We no longer stock the DTT, I wish we did, so I am not able to confirm if it is anti -LW. I really suspect it is.

We always found one or two patients with a new anti-K every year. The good thing is that K= blood is easy to find. Oddly enough my wife, a nurse of course, has an anti-K which was one of the first antibodies I identified while still in school. Luckily I am K= so that was never an issue with our children. Her anti-D on the other was a much more significant bother. Her anti-S has not been an issue either. Some how I suspect she is what we fondly refer to as a "responder".