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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.

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

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.

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.

Simular to AMcCord, above, except that once something like a massive transfusion protocol starts, we follow a documented P&P to get further units ready until the MTP is called off. We do the ordering during that time ourselves. Scott

I believe there is a field for Visual Inspection on page 1 of the product dictionary. If you enter Y, users are prompted during product login.

For Mass Transfusion and Emergency Release - Yes, we accept verbal orders for products for immediate transfusion and blood bank staff will place orders for what we need to carry through with the product requested. Once the dire emergency phase is past, nursing staff is asked to take care of the additional orders. My medical director and I feel that our #1 priority is to focus on what is best for the patient, not the paperwork. If the request is STAT but less urgent than a MTP or emergency release, we ask the person who called to take care of the order. We will start doing what is necessary to get product ready for release, but release comes after we receive an order.

I'm not sure how ours is set up differently, but we have to enter a Y or N on "product integrity OK?". We can't get past it, like the volumes on FFP or PPH. I could ask our IT guy if he knows how to make it mandatory.

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

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

Here's the official lingo from my policy: PRINCIPLE: The Blood Bank performs correlation of tests methods to evaluate the results of the same test performed with different methodologies. Methods in Blood Bank may not correlate 100% due to sensitivity and specificity of each test method. The goal of correlation of methods is not to achieve perfect correlation, but to understand the sensitivities, specificities, and limitations of the different methods used in Blood Bank. Some methods (e.g. Tango and LISS antibody screen) are not used interchangeably, but comparatively, when interfering substances (rouleaux, cold agglutinins, etc) may interfere with a particular method. No method in Blood Bank will always detect all clinically significant antibodies.