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  1. There is absolutely no reason to give group O red cells to a recipient who is A3. Even if the patient does develop an anti-A1, unless that antibody is reactive at strictly 37oC, they can still receive A1 red cells, but, if the anti-A1 does react at 37oC, there is no reason not to transfuse with A2 red cells that are IAT compatible. Personally, I have never seen loss of A or B antigens through ALL, but I have with AML. In fact, in one case, we were able to follow whether the patient was in remission or relapse by the strength of the reaction of the A antigen with various anti-A reagents, but this was many years ago, and I honestly can't remember whether these were human-derived polyclonal reagents or early monoclonal reagents.
    7 points
  2. If the test is showing no immediate rouleaux or agglutination due to a "cold reacting" antibody, I'm afraid that I am at a loss to see why anyone would leave the tests to see whether one or the other develops. Rouleaux is clinically insignificant in terms of blood transfusion, and ditto "cold reacting" antibodies, unless they are of wide thermal amplitude (in which case, there would almost certainly be agglutination visible straight away. Why waste reagents and expensive technician's time investigating a clinically insignificant phenomenon?
    7 points
  3. I believe the old saying is, "If the computer ain't happy, ain't nobody happy!!"
    6 points
  4. Giving O units (or A2) keeps our computer happier on patients with documented anti-A1. Of course, that is the prime objective these days, right? We bow to our computers!
    6 points
  5. Forgot to add, Plasmalyte is also FDA approved for use with blood components. No data :). In our OR, there is no normal saline at all, just Ringer's Lactate and Plasmalyte, the latter used for blood component administration. Plasmalyte is slightly more expensive than normal saline, but also somewhat less toxic.
    3 points
  6. I haven't seen a rebuttal but the FY system is reported to be a problem with storage. It was reported by : Williams D, Johnson CL, Marsh WL. Duffy antigen changes on red blood cells stored at low temperature. Transfusion. 1981 May-Jun;21(3):357-9. doi: 10.1046/j.1537-2995.1981.21381201813.x. PMID: 7233520.
    3 points
  7. I went back to your original post and it clearly said "Trigger" for some posters. My lab only uses the microscope for FMH screening tests and rarely (like once in a blue moon) looking for mixed field during post-transfusion reaction investigations. I would consider it to be looking for Zebras, as Malcom said, to want to see rouleaux or a cold-reactive antibody by letting tubes "sit before looking under the microscope" (slightly adulterated version, my apologies). I didn't see any mention of "only for ABO discrepancies" or even "reverse type". I've seen cold reactive antibodies look like rouleaux and rouleaux that gave the same appearance as cold reactive antibodies. Some are helped to be clearer with saline replacement, some not. That's probably where I stopped looking at these things under a microscope. We predominantly test using automated gel method with tube usually being the "come to the rescue" method to not see just those things you were talking about. Do I saline replace or pre-warm the test components for those things? If I need to, but I try not to wake the sleeping beasts so I don't see them in the first place.
    3 points
  8. If there ARE extra reactions in the back type, then they do need to be resolved IF, and I mean IF, they look as if they could signify that the forward ABO type is false. That having been said, I STILL would not go looking for rouleaux or agglutination that was not present when the tests are read at their normal incubation period and temperature. Why would you want to look for a herd of Zebra, when you hear a herd of Horses (thank you John C Staley - or, at least, I think it was you who used to say this to me on a regular basis - apologies if it was not - but it was a great comment!)?
    3 points
  9. I think we're confusing ourselves. I was referring to the original post which suggested a modification of procedure in order to enhance rouleaux/colds. Serological assays are typically read "without undue delay", i.e., immediately. If some techs have a practice to "let tubes sit before looking at them", that could be construed as deviating from the procedure, unless they have some bizarre and very specific local instruction to do so.
    3 points
  10. I believe most of these tests will fall under 1976-Type LDTs which fall under enforcement discretion. The immunohematology tests that may fall the new rule would be modifications to manufacturers' instructions (i.e., you use the reagent/test in another method, you use a different specimen type or extend the specimen acceptable time limit).
    3 points
  11. Transfus Apher Sci. 2023 Jun;62(3):103641. doi: 10.1016/j.transci.2023.103641. Epub 2023 Jan 13. Association of crystalloid fluid infusion with intravascular hemolysis and organ dysfunction in hematopoietic stem cell transplant patients Melissa R Holloway 1, Thomas Fountaine 2, Kelly Henrichs 3, Tate Feeney 4, Jeffrey Andolina 5, Kristen O'Dwyer 6, Jane Liesveld 7, Neil Blumberg 8, Eric Huselton 9 Affiliations expand PMID: 36653255 DOI: 10.1016/j.transci.2023.103641 Abstract Endothelial cell activation and injury is common after hematopoietic stem cell transplant (HSCT) and is associated with many post-transplant complications. An underexplored mechanism of endothelial cell damage in this population is the infusion of normal saline (NS, 0.9 % sodium chloride) and other crystalloids, as NS use is associated with adverse outcomes in other patient populations. We hypothesized that the infusion of unbalanced crystalloids during HSCT may lead to changes in biomarkers commonly associated with red blood cell (RBC) hemolysis in patients before and after infusion, and that markers of endothelial and end-organ damage during admission may be associated with markers of hemolysis and total crystalloid use. Samples were collected from 97 patients. From pre-fluid infusion to post-fluid infusion, mean haptoglobin decreased (11.7 ug/ml vs 8.4 ug/ml; p < 0.0001), hemopexin decreased (549 vs 512 μg/ml; p = 0.005), and red cell distribution width (RDW) decreased (15.7 vs 15.6; p = 0.0009). During admission (mean 19.4 days, SD 9.9), all markers of tissue and organ damage, including mean creatinine, lactate dehydrogenase (LDH), blood urea nitrogen (BUN), total bilirubin, AST, and ALT, increased from admission to peak levels (p < 0.0001). On linear regression, fluid volume (ml/kg) of crystalloid infusion positively predicted post-fluid infusion cell-free hemoglobin (r(96) = 0.34, p < 0.0001), free heme (r(96) = 0.36, p < 0.0001), and peak LDH during admission (r(75) = 0.23, p = 0.041), and negatively predicted post-fluid infusion hemopexin (r(96) = - 0.34, p < 0.0001). Unbalanced crystalloids may contribute to hemolysis and endothelial damage in HSCT patients. Alternatives such as buffered crystalloid solutions (PlasmaLyte, Lactated Ringer's) may be worth investigating in this population.
    2 points
  12. The preferred solution for administration of blood components should be Plasmalyte. Less hemolysis in vitro. Normal saline is toxic to patients and should never be used, in my opinion. Causes a metabolic acidosis and kidney injury. Ringer's lactate is fine too, but as you note, is forbidden (based upon no data whatever) by FDA. The only patients who might benefit from normal saline are those with a metabolic hypochloremic alkalosis, which is very rare. Our enthusiasm for normal saline was entirely misplaced. Randomized trials show it to be harmful and increase mortality in critically ill patients. Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW, Self WH, Rice TW.N Engl J Med. 2018 May 17;378(20):1951. doi: 10.1056/NEJMc1804294.PMID: 29768150 Free PMC article. BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration among critically ill adults. ...METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial in five intensive care units at an academic center, we assigned 15,802 adul … Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators.N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27.PMID: 29485926 Free PMC article. Clinical Trial. BACKGROUND: Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS: We conducted a single-center, pragmatic, multiple-crossover trial comparing balan … Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW; SMART Investigators and the Pragmatic Critical Care Research Group.N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018 Feb 27.PMID: 29485925 Free PMC article. Clinical Trial. BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five …
    2 points
  13. Could be an antigen within the Knops Blood Group System. They are notorious for "going off" on older red cells, but the antibodies are not renowned for being clinically significant.
    2 points
  14. Your guess is as good as anyone else's. . I suspect the FDA will continue doing regulatory stuff until told to stop by Congress or some court. I'd assume they will regulate LDTs as they have proposed.
    2 points
  15. I'm still wondering why you want to look under the microscope and why you want to see cold-reactive antibodies and rouleaux. Are these things written into your SOP and following the manufacturer's instructions?
    2 points
  16. Malcolm, thanks for your feedback- my sentiment exactly, I don’t see the point of restricting transfusion with only Group O red cells- it seem unnecessary. Some laboratories here in Oz are too cautious, our standards/guidelines mention exactly what you’ve stated, unless there is an allo-anti-A1 active at 37, the requirement is IAT compatible crossmatch (so A2 transfusions would suffice). Interesting to hear about your experience with loss of A or B antigen and AML! I’ve only seen cases with AML as well , not ALL. Publications also only mention myeloid leukaemias. You’ve inspired me to follow through with another patient of ours and their progress. 🙂
    2 points
  17. Winnie

    Welcome Winnie

    Thanks all! Hello from Down Under! Looking forward to learning and connecting with everybody across the world.
    2 points
  18. I just answered this question. My Score PASS  
    2 points
  19. Totally agree! In all honesty, we do whatever we can to NOT encourage any COLD or Rouleaux interference. They're a nuisance!
    2 points
  20. "the presenter stated specifically that NOTHING has been grandfathered. " I think the presenter is mistaken. The FDA specifically noted that the area of rare reagents and cells, and similar testing would not be subject to LDT enforcement. Of course, all the opinions in the world matter not a bit until the FDA actually acts or does not act. I cannot imagine they want to be inspecting every tertiary care hospital and blood center reference laboratory for this purpose. And most of the things we are discussing in the transfusion service and immunohematology lab are not used to provide diagnostic results to practitioners, but rather used for internal resolution of therapeutic decisions. Quite different from your average laboratory test which provides quantitative or semi-quantitative result to physicians and other practitioners who make decisions based upon lab results. Perhaps a nuance, but a real difference. If the FDA insists we validate the use of a potent anti-HPA1 anti-platelet antibody in our decision making, we're out of luck :). Ain't happening. Interestingly, much of what we do in clinical medicine has not been "validated" or subjected to FDA-like regulation. Such as using autologous or allogeneic stem cell transplants, liver transplants, using a stethoscope or looking at a patient's retina with an ophthalmoscope. No validation. No data to speak of at all.
    2 points
  21. Yup. What Neil said. We do not give RhIg prophylaxis for women of childbearing age if they have received Rh Pos red cells, but will offer it for Rh pos platelets. Once a full unit of red cells is in, it's a lot to mitigate, and if they're getting 1 unit of Rh pos red cells, they're usually getting MTP and many more Rh pos products. Plus, treatment for anti-D in pregnancy has gotten pretty sophisticated, it's certainly not pleasant for mom, but it can be done. The patient has to survive first!
    2 points
  22. I did come across one article where the author recommended changing guidelines for the use of Lactated Ringers in transfusion but only in times of "Rapid Infusion" such as during trauma. I would suspect there would be too many clots in the tubing otherwise. I would imagine there needs to be much more study on this with specific guidelines created. I work in a small hospital and like that it is black and white to NOT use the Lactate Ringers. With the Blood Bank being responsible for all transfusions, I wouldn't want to be a part of a situation where someone used a solution when it was not indicated that resulted in a bad outcome. I'll embrace change when the Circular says otherwise What articles has the OR read and offered? Is the surgeon previously military? Just wondering where they saw that Lactated Ringers has been used....
    1 point
  23. We had to purchase a set of screening cells from a different vendor for DTT treating cells for Darzalex patients because when we validated it, the Duffy antigen we were testing didn't survive the process consistently. It was fine on Alba cells but not on Immucor cells.
    1 point
  24. You are quite right Jason. I also remember a similar paper, written by Jill Storry, entitled "Long term preservation of red cell antibody identification panels in low ionic strength solution." This was published in Medical Laboratory Sciences 1987; 44 (4): 350-355, but was based on the winning Margaret Kenwright award presentation at the Annual Scientific Meeting of the British Blood Transfusion Society, London, UK on 4th September 1986. This was when Jill was a Senior Medical Laboratory Scientific Officer at the South Western Regional Transfusion Centre of the National Blood Transfusion Service in Southmead Road, Bristol. She has done rather well for herself since then, now being a Professor at Lund University. Unfortunately, I don't have a DOI for this paper. At the time, I was working at Mayday Hospital in Croydon, London, and wrote to her to clear up a couple of queries I had. In early January 1988 she wrote back to me and, in this reply, she stated, "Can I also draw your attention to the fact that the original trial (her original trial) was done using frozen re-constituted red cells. It has subsequently been pointed out to me that when using fresh cells for screening purposes there is significant loss of Fy(a) and Fy(b) antigens over a two week period. This phenomenon has been well documented (see below) and is due to the release of proteases upon leucocyte aminoglycoside interaction. Gentamicin is of course, an aminoglycoside antibiotic. We have overcome this problem completely by leucocyte depletion using a Sepacell 500 filter, and I hope to submit a short communication to the IMLS journal describing the results of this modification." I haven't got a reference for this. The paper to which Jill was referring to in her letter was: Malyska H, Kleeman JE, Masouredis SP, Victoria EJ. Effects on Blood Group Antigens from Storage at Low Ionic Strength in the Presence of Neomycin. Vox Sanguinis 1983; 44 (6): 375-384. DOI: 10.1111/j.1423-0410.1983.tb03660.x All that having been said, I would be surprised if all screening cells and antibody identification cells were not now leukodepleted. In addition, of course, apart from certain areas of Asia, neither the Fy(a), nor the Fy(b) antigens can be regarded as high prevalence antigens, and those antigens within the Duffy Blood Group System that can be regarded as high prevalence (Fy3, Fy5 and Fy6) are vey different to both Fy(a) and Fy(b), and so it is doubtful that these would weaken substantially upon storage.
    1 point
  25. Mabel Adams

    old glass saws

    Some of you more "experienced" people will remember the little saws that we used to score the microhematocrit tubes so we could break off the part with the immature red cells for antigen typing someone who had been recently transfused. What the heck were those saws meant for originally? I feel like they came with something else in the lab. Were they for general chemistry glass tubing? Also, what tool works well now for scoring the plastic-coated glass microhematocrit tubes since those little saws aren't available? I found a few centimeters of staples (ready to be put in a stapler) could work. Hack saw blade?
    1 point
  26. REN_NH

    old glass saws

    We used a "Machinist File" to cut glass crit tubes back in the day for baby Bilis. You can get them for less than $10 at Grangier or other suppliers.
    1 point
  27. I just answered this question. My Score PASS  
    1 point
  28. Cliff

    old glass saws

    For some reason I remember them being simple knives. Something like this, it just needed to score the glass, or now, plastic covered glass.
    1 point
  29. Annan

    BloodBankTalk: CJD

    I just answered this question. My Score PASS  
    1 point
  30. Route 1, that is how I got my SBB. I went to Rush University in Chicago.
    1 point
  31. Malcolm, I've up graded that from Zebras to Unicorns. Thanks for remembering.
    1 point
  32. I just answered this question. My Score PASS  
    1 point
  33. This month's challenge is simple. Visit Yup, it's that simple. Visit, Take a look in the menu and discover a section you've never seen, Make a post, Upload a document, Respond to a post, Or again, simply visit. Here is the history for 2024, let's see if we can get xxx visits for June 2024. We've already crossed 100,000 visits a few times in 2024, let's see if we can do that again this month.
    1 point
  34. Wow, we crushed this goal! Great work!
    1 point
  35. I just answered this question. My Score PASS  
    1 point
  36. Kim D

    HemeLabTalk: HbF

    I just answered this question. My Score PASS  
    1 point
  37. I just answered this question. My Score FAIL  
    1 point
  38. SueR

    HemeLabTalk: HbF

    I just answered this question. My Score PASS  
    1 point
  39. I just answered this question. My Score PASS  
    1 point
  40. I took my exam in 2017 after going through the NIH SBB program in Maryland. I highly recommend that program to anyone who is looking for in person program. The passing rate after the program for the SBB exam is at 90% for the last 10 years. It is free, you work there and get paid and learn from the best in the industry, and it is in person. I did not study outside the class provided materials and got 630 on the exam. Prior to that I had 6 years of BB leadership experience in the smaller Regional hospitals. I can provide contact info for the program if anyone interested.
    1 point
  41. My question is, why are you looking at them under a microscope? My transfusion service stop doing that back in the late 80s!
    1 point
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    1 point
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    1 point
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    1 point
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    1 point
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    1 point
  47. I believe internal QC or non-patient testing is not covered by the FDA regs. Only tests used to report patient results.
    1 point
  48. I attended a webinar presentation on this and the presenter stated specifically that NOTHING has been grandfathered. There are some items that the FDA has said it would still use enforcement discretion, but was very much above my understanding.
    1 point
  49. Another inspector who is a bureaucratic and clinically ignorant rigid thinker. My sympathies. There is no reason to document early infusion rates, and these vary by patient due to clinical condition. This is just a guideline and not a requirement, as the inspector would know if they had any bedside clinical practice experience. Just say it's a rough guideline, not a requirement, and clinical judgement will determine the infusion rate for each patient.
    1 point
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