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I offer the following based on experience with the MMA and antibodies to antigens of high prevalence and should not be taken as clinical recommendations. The National Reference Laboratory for Blood Group Serology for the American Red Cross has performed Monocyte Monolayer Assays (MMAs) in over 200 cases of patients with anti-Yta in order to determine which patients have antibodies of potential clinical significance. The MMA has been performed for more than 30 years. The reason to perform the MMA is to conserve the supply of Yt(a-) units for patients who have had either had decreased survival of transfused RBCs or who have a positive MMA. But the MMA is only useful for determination of transfusion recommendations for the mother, the MMA for prediction of Hemolytic Disease of the Fetus and Newborn has not been found to be useful in studies performed in George Garratty's Research Laboratory in Los Angeles. For cases like these, an MMA is recommended if blood is thought to be needed for the mother at delivery. Then if a physician determines that the mother can donate autologous units that would be useful. In some cases, 3 different donations can be made with the first two being frozen, one into two aliquots for possible use by the infant and one as a whole unit for the mother's possible use. The final unit can be drawn in order that it will be in-date at the time of the planned delivery. Autologous units do not generally have to follow the same rules as allogeneic donation, and can allow for more frequent donation and at a lower hemoglobin in accordance with the physician order. Alternatively or in addition, a request can be placed by an American Rare Donor Program member for potential units for delivery if autologous units cannot be obtained. And, after delivery, when the woman is eligible for donation, she should be encouraged to donate, not only for herself, but for others. Her siblings should also be tested as they have a 1:4 chance of being Yt(a-). It is assumed that pregnancies like these are monitored by non-invasive means. Most often, antibodies such as anti-Yta, seldom clinically significant for HDFN, are monitored by titer, reviewing for increases in titer (although not mentioned), and then, by clinical protocol. Opinions vary on critical titer value in non-D antibodies, but most agree that increases in titer are reviewed for further studies or early delivery. Perhaps not especially needed in this case, but in cases of antibodies to high prevalence antigens, knowledge of the father's ABO and D status, especially prediction of zygosity of the father's D type might be useful in the very rare event of HDFN because O D negative Yt(a-) blood may be challenging. Sandra Nance, MS, MT(ASCP)SBB, Senior Director, American Rare Donor Program

Another reason why our computers are better at selecting ABO compatible units than serological testing is.

First, you have a discrepancy between the Mom's Rh type on the pre- vs. post-delivery specimen. That needs to be resolved just as you would need to resolve an ABO discrepancy. I would suggest that a new specimen be collected from the Mom and tested. If the new specimen's Rh type agrees with the pre- specimen, then it would indicate there was a problem with your post specimen either misidentification or contamination. Repeat the rosette test on the newly collected post specimen. If the new specimen's Rh type agrees with the original post- specimen then you have your answer that the rosette test is false positive due to the Mom having a weak expression of D which interferes with rosette testing. You are not detecting Rh + fetal cells, instead you are detecting Rh + (weak) maternal cells which would explain why the rosette test is positive but the KB stain is negative. You would also then need to follow up as to the pre- sample and whether it was misidentified at collection, etc.

Hello All, I passed the test last week. Thanks to all the board members. I learned a lot from all the topics discussed here as well as the educational material.

On p. 563 of AABB Tech Manual 18th edition, it only mentions that titer methods other than "saline AHG 60 minute incubation" in tube may result in higher titers and "should be validated with clinical findings" (see Malcolm's post, above). So it does not seem to say one cannot use gel or other methods, just that you need to document validation. I have always been a bit uncomfortable with identifying an antibody with gel (for a prenatal), then doing the titers in tube. But then again, I guess it is the comparison of the series of tube titers that they are looking at. Scott

The AABB Technical Manual states that antibody titers should not be performed using gel technology, so we revised our procedure to go back to tube method.

I would be very worried about any extension, for exactly the reason you have given (i.e. that she is pregnant) and has already shown herself to be a responder.

We transfuse febrile patients regularly. The nurses look for an elevation in temperature (1.5 C) above the starting temp to call a febrile reaction. I don't feel that we are doing a large number of workups simply because the patient transfusion started with an elevated temp.

So we have had 2 patient mysteries in the past week. One of them probably has a simple solution....but is just not something I have ever seen in over 30 years. The other one is more of a mystery. 1st case: We received a Cord Specimen on the baby from an A NEG mom to evaluate for Rhogam. The baby typed 4+ with Anti-A, but 1+ with Anti-B. We did wash the cells many times. We also obtained a heelstick but obtained the same results. I am used to seeing weak A typing on newborns; but not used to seeing it with Anti-B (but then statistically, I have seen many more A's over the years than B's); especially when it was so strong with the Anti-A. Have any of you seen that weak of typing with Anti-B on newborns, or are there any other thoughts on what is occurring here? 2nd case: 62 year old male with diagnosis of COPD, Dyspnea, GI Bleed, Chemo (as recently as yesterday). So ongoing problems. He has had MANY transfusions of RBCs and Platelets over the past year; including past 3 months. The patient is A POS. Yesterday, he was transfused with an O POS Platelet (we only keep 2-3 in-house at any given time so just have to give what we have, and do so by outdate). Anyway, after receiving only 151 cc's of Platelets, he had Chest Pain, Respiratory Distress and Vomiting. He was transferred by ambulance the 1 block to the Hospital ER. All of our clerical check was fine. Our Policy for giving Platelets is that we just have to have a historical type on the patient; it does not have to be a current type. However, the Cancer Center had drawn a HOLD specimen that morning so as it turned out, we did have a pre-transfusion specimen (just had not been tested yet). Upon testing both the pre- and post- specimens, the only issue we came across was that the pre-transfusion IgG DAT was Negative, but the post-transfusion IgG DAT was 3+. When we spoke to the Medical Director of our Donor Facility, he said to report it as a hemolytic transfusion reaction. Problems with that are: After whatever treatment they gave patient in ER, he was sitting up and feeling just fine. Also, no indications of it being TRALI. So we became concerned that perhaps we had a platelet with a high-titer Anti-A,B. We performed an Eluate on the post specimen and tested it against screening cells plus A1 and B cells. All testing was NEG. Now we were really stumped. We had the patient re-drawn and now, several hours later, the IgG DAT had dropped to 1+. Not a dramatic drop in Hgb.....from 7.4 before transfusion, to 7.1 after transfusion, to 6.9 this morning. So my last "guess" was that perhaps he was just really unlucky and the donor of the platelets had an Antibody to a Low Incidence Antigen, and the patient just happened to be Positive for that Low Antigen?? So we are testing just the Lows that are on our panels (Cw, Kpa, Jsa and Lua). Of course there are a lot more Low Incidence Antigens that it "could" be if that is what caused this. But that decrease in strength of the DAT, in light of not really seeing evidence of hemolysis, is very confusing. And if it is an Antibody to a Low Incidence, due to his many transfusions of RBCs, is the Antibody attaching to his own cells, or to donor cells he previously received which may have been Positive for a Low Incidence Antigen? Any thoughts/ suggestions. Also, as I am completing this, my Tech. just brought me a gel card with the results from 2 of the Low Incidence Antigens. It looks like the card spun at an angle so I want it repeated, but it appears that the eluate is reacting with the Lua+ panel cell. But I wouldn't expect an Anti-Lua to cause a severe reaction in a patient like that. Anyway, will keep you posted on our serological results.....but if you have any other ideas/ thoughts, would love to hear them. Thanks in advance for your input, Brenda Hutson, MT(ASCP)SBB

Yes. We do not allow platelets and cryo to be transfused using the Belmont Rapid Infuser.

I am looking at the Participant Summary for latest CAP proficiency, anti-D titer. For tube testing using the "uniform procedure tube method" that CAP suggests, they reported the following results: 333 participants, mode 64, consensus range 16 to 256. For Gel testing "uniform procedure gel method", 138 participants, mode 256, consensus range 64 to 1024. Per CAP, Consensus is determined by the Mode +/- two of the most frequent titers. It looks like in the previous 2 surveys for the gel anti-D titers, the mode for gel was 1 to 2 dilutions higher than tube, but so was the consensus range. It seems like there are a fair number of labs reporting gel and if you report that as your method you should be compared to other gel titer users. I would also think as more instruments are implemented that can do gel titers, the number reporting gel will go up. And of course what ever you do, perform method correlation and communicate with the obstetricians any changes they may see in titer results. We are contemplating this also. Also I am little confused by ""Do you want it to be faster and more hands-off or more exact?" It seems to me that automated titers in gel should be much more reproducible. We are just starting to look in to performing titers on Vision.

We do as Baby Banker does, create a selected cell panel to rule out everything else. The game we play is how few cells can we run and have a valid rule out panel We have had several patients that we do every 3 days until delivery. One of our patients had Anti-c and Anti-E.

If you know she has anti-E, you can probably put together a custom screen of E negative cells. That screen would only be positive if she developed another antibody. Be careful that you cover all the antigens that the FDA requires. That list used to be in the Technical Manual. I think it is D, C, E, c, e, M, N, S, s, P1, Lea, Leb, K, k, Fya, Fyb, Jka, Jkb.

I think this is highly dangerous, and I also think that your Pathologist should tell your "LEAN" department to butt out, if you will excuse the language.

Our "LEAN" department makes us use everyone. In my opinion-this has cost us quality. Not a good idea to have a casually trained tech working-no SBB in charge for reviews.

We wrote this case report up and it got published in Transfusion Medicine. I can email the paper if anyone is interested.

I agree with all the above we have used O pos on all our massive transfusion patients and on any emergency release blood given to a male or female >50. We also use A FFP in any emergency release or massive transfusion patient. The only problems that we have run into as with any massive transfusion patient is how late we get the T/S and then the patient shows as an O pos and then after being in the hospital a while starts to show their true type. As far as antibodies, in an emergency situation there are risks, but death is what we are trying to prevent. We have not had very many patients that come back with antibodies and Anti-D isn't even usually the one made. More often than not it is a K or Duffy, possibly a Kidd.

to save into a Word document, click PrtScn, send to clipboard, then to put in document, click on spot you want it and right click and paste. On the popup boxes, if you want whole screen with the pop up, hit PrtScn, then cancel, then to put in document, click on spot you want it and right click and paste. You'll have to do some trimming then.

Oh WOW! You guys are amazing! We did not know this was an option. We've managed to add the visual inspection field (hard stop) under the other mandatory field. Honestly, this is making me way happier than it should. I think I need to get out more

Our Massive Transfusion Protocol states that blood bank/lab staff will place orders for subsequent products needed. Other than that, we have a "Written verification of Verbal Order" sheet that we complete and send to the patient location for the physician to sign. This is used in those circumstances where the nurses are too busy to order so blood bank puts in the orders. For Emergency Issue products, we have the physician sign a release for the use of the emergency products.

We also allow for verbal orders in exceptional cases (i.e. massive transfusion, patient bleeding in the OR). We document the call on the Verbal Order Log Sheet - includes the physician requesting, hospital number of patient, first/last name of patient, person phoning, type/number of products. it also includes a check box for the MLT to document the issue checks before either handing off a crate of blood components or shooting the component off in the pneumatic tube system.

Another caveat about doing titrations on the Vision is that it always runs all 10 (or 12?) dilutions. That will burn through a lot of reagent cells unnecessarily on a titer of 4! I agree with those above that it is critical that the OB/GYNs know that you are using a method that gives different results than their textbooks are based on. Every gel titer result should go out with a comment explaining how its results correlate to the literature for further evaluation of the pregnant person. At least nowadays they are likely to follow with Doppler ultrasounds rather than riskier, invasive amniocentesis. I think a review of the CAP survey results is very enlightening.

I work at a level 1 trauma center. During trauma/MTP the Belmont Rapid Infuser is frequently used. Up to 3 units at a time (any combination of RBC/FFP) are hooked up to large diameter tubing that drains into a large reservoir. The products mix together in the reservoir rand then are rapidly infused in about 1 minute. I also agree with David's comments about making WB.

Not mention that isoagglutinins may be absent entirely in the first half year to year of life, and in patients receiving intensive immunosuppressive/myeloablative therapy. So the source of your plasma may make a difference, if it was from patients in a hospital, as opposed to healthy blood donors.

Some individuals have very low titer/affinity antibodies, and this probably explains your negative results. Not all that surprising or uncommon.

Vox Sang. 2009 May;96(4):316-23. doi: 10.1111/j.1423-0410.2009.01167.x. Epub 2009 Feb 24. Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma. Shanwell A1, Andersson TM, Rostgaard K, Edgren G, Hjalgrim H, Norda R, Melbye M, Nyrén O, Reilly M. Author information Abstract BACKGROUND AND OBJECTIVES: The consequences of ABO-compatible non-identical plasma for patient outcome have not been studied in randomized clinical trials or large cohort studies and use varies widely in the absence of evidence-based policies. We investigated if transfusion with compatible instead of identical plasma confers any short-term survival disadvantage on the recipients. MATERIALS AND METHODS: The cohort of all 86 082 Swedish patients who received their first plasma transfusion between 1990 and 2002 was followed for 14 days and the risk of death in patients exposed to compatible non-identical plasma compared to recipients of only identical plasma. RESULTS: After adjustment for potential confounding factors, there was an increased mortality associated with exposure to ABO-compatible non-identical plasma, with the excess risk mostly confined to those receiving 5 or more units (relative risk, 1.15; 95% confidence interval, 1.02-1.29). Stratification by blood group indicated higher risks in group O recipients, especially when the compatible plasma was from a group AB donor. CONCLUSIONS: This study suggests that ABO-compatible non-identical plasma is less safe than identical plasma. Subanalyses by blood group suggest a role for circulating immune complexes. Our findings may have policy implications for improving transfusion safety.

The only thing I would worry about with pre-natals, where titers from one month are compared to the next, concerns things that may intermittently cause gel interference. For example, if I am not mistaken, CRP goes up and down with any pregnancy, and could cause gel interference (potentially upping the titer I would think) for one month but not necessarily the next. What would one do with gel titers were interference is noted in one specimen but not another? Or maybe this would never happen? Scott

We do our titers in tube. Years back when a lot of places had switched or were getting ready to switch to gel there was a conversation about the difference in titers due to sensitivity of gel. The basic conclusion at least in our geographical patient care area: we didn't want physicians to be getting different titers from different labs solely due to differing methodologies as it could lead to unnecessary concern/procedures for the patient. So we all stick with tube method. In those instances where we detect the antibody by a more sensitive method i.e. gel or Capture but the titer is negative then we report the antibody titer as less than 1 (<1). Jan

I feel your pain! So much for evidence based medicine

We were doing titers in the gel and kept failing our CAP surveys for titers. They were always one titer too high (CAP gives you a 3 titer range the results can be within to pass). After investigation (I was new at this job at the time) I found where the Technical Manual says that they shouldn't be performed in gel. (Like SMILLER says above). It goes on to state that there is a danger with interpretation by the physician and the higher results of unnecessary invasive procedures performed due to that combination. They, strangely, do not tell what studies they base that comment on. We switched to the tube method and haven't failed a survey since. We are in the process of deciding on new Blood Bank automation. When we saw the Vision, that seemed to be one of the "hot" selling points - the ability to perform titers. We questioned them about how they felt about it being contrary to AABB recommendations to do titers in the gel. The response was something like, "Do you want it to be faster and more hands-off or more exact? We would rather see it be more hands-off." (Not a direct quote, but you get the picture.) Personally, I would prefer the "exact" results to one that may or may not be too high. I would also prefer to pass my CAP competency surveys! Just saying.

We are a small facility which uses manual gel technology. We rarely see titers ordered. However, when reporting an antibody on a pregnant patient (detected and identified in gel) we faced this dilemma: the antibody was so weak it was not detectable in tube. We then started using gel for titers with the understanding that it is the change in titer over time that is significant. For proficiency, we use the split sample method every 6 months. CAP and State (NJ) inspectors have been OK with this.

Nice work, congrats! When I was doing my SBB training our reference lab manager/educator had an running bet, she'd buy dinner for any student that took an SBB exam and didn't get a question about anti-D,C and G. Don't think she has bought anyone dinner yet

We don't titre because we don't have anything to do with the mother's care, but I know the hospital down the street tracks the titre. As for the panel/screen, I take the antigen profile and circle all the required antigens. Then I select a cell that is homozygous for each one. I sometimes have to use cells from other panels or screens. I know the rule is that you can substitute two heterozygous cells for one homozygous cell, but I never do that if I can help it.

Agree with AMcord; we also learnt to check how and where the temperature was taken, i.e. ensure the same method and location was used before and during transfusion. We would sometimes see first temp under the armpit, second oral and so on. Catch this early and several febrile reaction workups were avoided, often enough to be worth the effort of checking the method.

It seems like those guys at Coulter 30 years ago had too much time on their hands... Scott

I agree with Malcolm's statement about trying to preserve ABO antibodies on the cells. This made me think for a second. At my facility when we prepare eluates we use cold saline for the first wash and then cold working wash solution for the remaining washes. I looked at the Immucor Elu-Kit package insert. It has the following statement in the limitations section. The degree of dissociation of antibody that occurs during the washing procedures. This may be minimized by washing in 1° to 10°C Working Wash Solution. In most cases, satisfactory eluates can be made after washing the cells with Wash Solution at room temperature.

From what I have been told by accrediting agencies here, different tests can only be combined into one test system if there are no unique aspects in testing or in problem solving when something goes wrong. I interpret that as meaning the antibody ID, DAT, and elution are all separate test systems because the testing method is very different. Different treatments, however, I could see being grouped into 1 test system (EGA, DTT, ficin) if you can "sell" them as being similar enough. Same goes for the adsorptions, in my opinion. I would rotate which treatment and which type of adsorption you do each year, but group them each into a test system (RBC Treatments as 1 test system and Adsorptions as a separate test system). If you group multiple tests into a test system, only one of the tests in that system need to have the 6 elements of competency assessed each year. However, you have to watch what you group into a test system! It seems crazy, but by the letter of the "law," we should be doing all 6 elements of competency for every test we perform if the procedure is not exactly the same. (I have read that even if the amount of a reagent is different, it would be a different test system. Crazy! ) In practice, this doesn't work for our site; we would spend more time assessing competency than doing real work! We decided to live on the edge and combine a few things into test systems, even though they are pretty different test procedures.

Remember that you can combine the 6 elements into 1 competency exercise. You may observe the tech while they are performing testing on an unknown (2 elements covered) and ask questions related to the exercise for problem solving (another element). Have them document the unknown as they would a patient (4th element) and ask them to perform the appropriate QC for the tests they are using. Once you've reviewed any intermediate worksheets/other paperwork (5th element). They will use equipment while they work (6th element or at least part of it). Cover as much ground as possible with each observation.

Our tolerance between the chart, thermometers, display, etc. for refrigerators is 1 C. The alarms are set to go at 1.5 and 5.5 C. Scott

In general we do our best to not detect antibodies that do not react at 37 degrees and IAT, but obviously reverse grouping is performed at room temperature, so you are occasionally going to find an anti-A1. We would probably not ignore this, despite the evidence that clinically evident hemolysis is very unlikely to nil. Our approach would probably be washed group O red cells. The reasoning is to minimize the infusion of incompatible soluble antigen and antibody from the ABO blood group. It may well be overkill in this setting, but we are now convinced that the use of so-called universal donor group O red cells and group AB plasma is likely harming some patients by increasing bleeding, multi-organ failure and infection through an immune complex/hemolysis mechanism. Traditionally, hematologists and transfusion professionals are only worried about massive hemolysis. Recent work by many groups suggests that low levels of hemolysis (say 10-50 mg/dl) are not benign. Free hemoglobin, heme and iron are clearly not benign in animal models. We know from experiments of nature such as sickle cell anemia and paroxysmal noctural hemoglobinuria that these sorts of "invisible" levels of hemolysis likely cause vasculopathy, platelet activation and thrombosis and predispose to nosocomial infection. Hence we are trying to never give transfusions that may contribute to hemolysis by infusing incompatible ABO antibody or soluble/cellular antigen. Hence the saline washing of group O red cells in some instances in order to avoid both antibody as well as antigen incompatibility. We have randomized trial data that this approach is safe (no excess bleeding) and reduces inflammation in cardiac surgery and improves survival in acute myeloid leukemia. Moreover use of ABO identical and washed (and leukoreduced) transfusions almost completely abrogates the last platelet refractoriness seen in patients with hematologic malignancy. Yes it's extra work and costs a bit more, but HLA matched platelets are expensive too :). Finally, since converting to this policy of ABO identical everything for all recipients we have seen our febrile and allergic transfusion rates decrease substantially, and our red cell alloimmunization rates to CcEe and K have decreased by 50% or so. We consider this good news. One reason patients with sickle cell anemia have such high alloimmunization rates, we suspect, is the tendency to use group O red cells (unwashed) which creates low levels of ABO immune complexes in non-O recipients that predispose to immune activation. No data on this, just suspicion and extrapolation from our clinical data.

It's definitely possible. Many our patients are running a fever for one reason or another. It's up to the physician to transfuse, as it is for any other patient, acutely ill or not. Scott

Hi Mabel, I am just setting a Journal Based Learning exercise for the Institute (I can't say the paper I'm using on here yet, as some of the members will be taking the exercise, and I shouldn't really give them any hints in advance of those who are not members on here), but I came across this statement, "Accumulating data indicate that the infusion of plasma which contains ABO antibodies may cause the rapid clearance of platelets, formation of immune complexes, endo thelial cell damage and multiple organ dysfunction.", and the authors of the paper give the following references: Heal JM, Blumberg N, Masel D. An evaluation of crossmatching, HLA, and ABO matching for platelet transfusions to refactory patients. Blood 1987; 70: 23-30. Benjamin RJ, Antin JH. AB)-incompatible bone marrow transplantation: the transfusion of incompatible plasma may exacerbate regimen-related toxicity. Transfusion 1999; 39: 1273-1274. Lapierre V, Mahe C, Auperin A, Stambouli F, Oubouzar N, Tramalloni D, Benhamou E, Tiberghien P, Hartmann O. Platelet transfusion containing ABO-incompatible plasma and hepatic veno-occlusive disease after hematopoietic transplantation in young children. Transplantation 2005; 80: 314-319. I have not read these cited papers myself, but the authors of the paper I am using for the exercise must know what they are doing, as they also cite a paper written by some bloke named Needs!!!!!!!!!!

The only reason I asked was because both ALG and ATG can cause a transient positive DAT that will become negative within a couple of hours of administration.

The Circular of Information (9/22/16) states "no medications or solutions may be added to or infused through the same tubing simultaneously with blood or blood components with the exception of 0.9% sodium chloride." When you transfusion whole blood or reconstituted whole blood for exchange you are creating a new product or medication. Since blood and blood products are considered biologic medication our hospital only transfuses one unit at time. However, if the patient has multiple lines which our traumas usually do then you can infuse multiple products just not through the same line. The other problem is if the patient has a reaction how are you going to tell which product is being transfused at the time of the reaction? Of course this is the same problem we see when patient's are placed on ECMO and both the RBC and FFP are placed in the circuit together.

Those dang physicians! Running up bogus charges! What we do is similar to Molly, above. The issue of changing billing regarding whether or not a unit is crossmatched or used does not matter to us. If we have an order for a crossmatch for compatible units, we do (and bill for) whatever work is needed to get those ready. if that involves a simple IS crossmatch, that's what the patient is charged for. If we have to screen 10 units to find two Ag-compatible, we are going to charge for all of that work. Scott

You took the words right out of my typing fingers Malcolm!

In my opinion: Antigens are unlikely to "wash away" or be "altered" by washing with normal saline. [One exception: Lewis antigens may be liberated during washing.] Antibodies, on the other hand, are more likely to be eluted from red cells by excessive washing with acidic saline. I doubt any publications exist that prove excessive washing has the effects you describe, but I would love to be proved wrong.

About half of our surgery patients are first timers to the blood bank. Since we need two independent types, we use the pre admit type and screen as the first type and a heads up for any antibodies. They always get redrawn the day of surgery for the type and screen we will crossmatch with. That may be 28 days later or the next day. We then have 2 independent types for our ABO/Rh confirmation. We do not extend sample dates past 3 days without a really, really good reason and pathology approval.

Of course it is, it would be an honor to have it added here.

BUT, if you are doing this yourself, do you let your supplier know of your suspicions, so that they can put any other blood components/products manufactured from the same unit into quarantine until you have your results.