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Just a question regarding ce (f) ag when dealing with warm autos. If the patient phenotypes as R1R2 is it prudent to provide c neg rbcs or just go with Rh ag specific? I have always gone with ag specific but I find the reference lab used by my current assignment recommends "c" neg. Looking for opinions please. Thanks in advance.

It's a pretty interesting phenomenon. It sometimes seems like the entire hospital is run by a nursing council/committee, which can only be overruled by medical staff and even then, physicians don't always get the last word depending on the topic (though sometimes that's probably a good thing!). That is why it is absolutely essential to cultivate some key relationships with nurses in various disciplines. The team approach is preached but I think we - the lab - have to work very hard to be included in the team in a truly meaningful way. Always a work in progress. The current thinking at my facility is that everything has to be focused on easing the life of the nurse so that they have the time to best care for their patients. I have no problem with doing what we can to improve patient care, but sometimes it puts us in some interesting job responsibilities as we 'ease their workload'. There also seems to be a mindset of 'Mother Knows Best' and of course Mother is a nurse. Often Mother does know best, but sometimes she needs to listen to advice. Another issue is that many nurses do not truly know what the lab does and how, do not understand that we are tightly regulated and that we are actually well educated people. We often bump into issues where we have to say (very sweetly, of course) - I don't tell you how to do your job because I'm not educated to do your job (unless you are messing with my blood products!), so please do not tell me how to do mine.

Oh I see; sorry. Well, if we have a patient who has made an anti-f (usually an R1R2), we usually say give either R1R1 or R2R2, but, if the patient has an auto-antibody and has not got anti-f, we would recommend just Rh antigen specific, and by that, I mean you could give an R1R2 patient virtually anything in the way of Rh, so I still go with what you say!!!

A lot of folks like to run 20 of everything. There is no regulatory requirement on the number of samples you need to use. Whatever you feel is necessary to make you feel comfortable. Personally, I would validate the temperature in each of the card slots (you'll need a small thermocouple, this was not well thought out by Ortho) and then verify the centrifuge rpms. The timer is digital so it needs no validation. I don't see that you need to run patient specimens, it is not reagent, it is equipment. Would you run specimens to verify a heat block?

We have a couple of policies that might have helped (although if the tech was convinced that the reactivity in solid phase was a false positive, he might still have missed this--our expectations are powerful). We require (well, there are some exceptions) that 2 double dose (homozygous donor) Jka positive cells not react in gel before we can rule it out. I have seen too many anti-Jka antibodies that react with one cell but not another in gel. We pretty much never rule it out with just "positive" cells. I know I look particularly hard at whether something "sort of" fits a Kidd antibody because of their tendency to be weak to undetectable. If all of the positive reactions are on Kidd double-dose cells, I will be doing some extra work to rule it out. Antigen type the patient, as Malcolm says. We train and it is in our procedure that the gel card must be "QCd" after running which includes looking for proper centrifugation of the card and whether the cell and plasma volumes are correct. I can't promise that no one ever gets lazy and skips this but then they are not following the procedure. Some other options would be that gel cards run to follow up on questionable solid phase results have to be incubated for 30 minutes instead of 15 (we have validated up to 40 minutes which is about the maximum allowed I believe in MTS gel). This will sometimes bring out a weak antibody or make it react with more cells. It does not change the non-specifics much usually.

Most EMRs with CPOE have a way for nurses to enter orders (in ours they have to choose verbal or phoned) that then show up later for the provider to sign off on. The RN isn't really ordering anything any more than they used to before CPOE when the transcribed the orders from the patient chart into the computer. We give crossmatched as soon as the necessary testing is done. Our massive protocol is unrelated to crossmatched vs. uncrossmatched. If the patient had a special need for irradiation we would have to override to issue non-irradiated units but we could do it. We don't capture irradiation need from anything except our history or the current order. If the need is in our history, we would do what we could to honor special needs and get pathologist permission to deviate if need be. If there's no time, we notify the provider and then get the pathologist in on it. One thing the pathologist can help determine is how high the patient's risk of GVHD is. I'm no expert but I know that they never seem to worry about the non-irradiated units we transfused to the newly diagnosed leukemic before they gave us the special need of irradiation. Three months post BM transplant might be a different story. GVHD is caused by live T-lymphocytes in the donor blood that are capable of multiplying and establishing that clone in the body of someone whose immune system can't destroy the foreign lymphocyte. That means any active donor lymphocytes left after all the bleeding is done could conceivably multiply and cause GVHD in a patient who is at great risk for it (say, recent post bone marrow transplant, rather than just a transplant candidate). Leukoreduction will have reduced the number of lymphocytes present in the donor units. Malcolm's point that old stored blood has fewer live T lymphocytes would also contribute to improving the odds (if you aren't having to use your newest stock). It almost seems to me that the effort might be to "save the best wine for last" and fill them up at the end of the hemorrhage with irradiated units. Of course, as other posts point out, sometimes the last unit is only the 3rd one given. Do the best you can, be able to justify your decisions, document everything and discuss it with your staff periodically because they are't reading the procedure in the middle of a massive transfusion.

Back in the day, they used to include a vial of O cord cells with panels. I believe they quit because they had not had a practice of getting consent to use those cord cells. I imagine it would be quite a headache to set up a system for getting consent and the parents might expect to be reimbursed for the commercial use of their baby's cells. If I am remembering correctly, I doubt that anyone will be producing cord screen cells any time soon in the US.

I'm not trying to play armchair quarterback. I was only adding a light shade of gray regarding patients with special transfusion requirements.

It could be. We see a number of pregnant women per year, with anti-c, who are either group A, but appear to have anti-A in their plasma when we group them, or are group B, but appear to have anti-B in their plasma when we group them, because the reverse grouping cells are (apparent), dce/dce and so will react with IgM anti-c.

Excuse me for saying so, as I am in the UK and not the USA (so I may be "poking my nose in where it is not wanted"), but, surely, if the person being called specialises in a different department, and you are asking a "specialised question", then the person being asked the question should say that they do not know the answer, but will ask someone who does, and get back to you? Surely, if the question is important, the answer should be accurate and the person answering the question should not just "wing it"? Just sayin!

The patient is rr. Reference reported it as "unidentified antibody with anti-c specificity".

Do you mean a root cause analysis?