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Showing content with the highest reputation on 09/19/2018 in all areas

  1. 3 points
    Mabel Adams

    Antibody I.D. Work-ups

    Sometimes adaptations are made depending on limiting factors. Maybe time is of the essence because the patient is bleeding or going into major surgery so more panels or methods are run at once to arrive at a conclusion more quickly. Sometimes there is only limited amount of patient plasma so fewer tests are run at a time and further testing determined based on the results of early testing. I always say that after the first panel with usual algorithm for rule-outs it ceases to be as much about the usual rules and starts to be more a matter of judgment and experience. The "rules" help newer people and generalists stay on track. If it gets complicated, they can call on more experienced people, including waking me up at 2 AM if need be.
  2. 2 points
    I agree with new pain. I find that the BP question is difficult because of patients being treated concomitantly for either hypo or hypertension, not to mention getting up to use the bathroom or getting riled by being visited by that annoying person who says they deserved to be sick because of something they have done. Or maybe they got the post-op cancer diagnosis during the transfusion. I have heard 30 mm Hg suggested but I think it depends on how it is applied. I look forward to someone having a clear cut answer for you.
  3. 1 point
    Malcolm Needs

    Gold Medal.

    I am enormously honoured to announce that I am going to be awarded the Gold Medal of the British Blood Transfusion Society at their Annual Scientific Meeting in Brighton this year. It is awarded to an individual for their exceptional and long standing services to the Society and to the practice of blood transfusion in the UK. Sorry if this sounds egocentric, but I am very excited.
  4. 1 point

    Suspected Transfusion Reactions

    The grocery list below is what is in nursing policy at my hospital, with my notes in italics. This is their reference cited in the policy: Berman, A. & Snyder, S. (2012). Administering intravenous therapy. In Skills in Clinical Nursing (7th ed., 511-512, 516). Upper Saddle River, NJ: Pearson Education Inc. A. Recognize and report any of the following signs / symptoms of a transfusion reaction to the Physician and blood bank immediately for consideration of transfusion reaction work up: 1. An immediate hemolytic transfusion reaction may contain any or all of the following clinical presentations: a) Fever, chills, or both (specifically 1.5 F increase) b) Nausea or vomiting (also sudden onset of diarrhea) c) Headache d) Pain – localized to the back (also flanks, abdomen, chest, head, and infusion site) e) Chest constriction (also sudden onset of cough) f) Dyspnea and cyanosis g) Subjective feelings of distress – sometimes reported as a “sense of impending doom” (anxiety, agitation) h) Hypotension, tachycardia or both (significant change in BP) i) Hemoglobinuria (dark urine, anuria in extreme cases) j) Unexpected degree of anemia due to hemolysis of transfused RBC’s k) Shock l) Rash m) Feeling of heat along the vein used for infusion 2. Delayed Hemolytic Transfusion Reaction (24 hours to 2 weeks post-transfusion) may contain any or all of the following clinical presentations: a) Fever, chills, or both b) Jaundice (sclera) (increase in bilirubin) c) Pain-localized to flanks, back, abdomen, chest, head, and infusion site d) Dyspnea e) Sudden unexplained fall in hemoglobin 7-14 days post transfusion f) Continued anemia despite transfusion therapy g) Hemoglobinemia and/or hemoglobinuria 3. Febrile Nonhemolytic Transfusion Reactions (occur at the end of the transfusion or up to 2 hours later) may contain any or all of the following clinical presentations: a) Fever – occasionally b) Chills, colds c) Discomfort d) Rigors – occasionally e) Headache f) Nausea – some patients may vomit g) Dyspnea 4. Allergic Reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations: a) Intensely pruritic, localized or disseminated urticarial eruption (well circumscribed, discrete wheals with erythematous, raised, serpiginous borders and blanched centers) b) Generalized pruritis may precede eruption or generalized erythema or flushing of the skin. c) Angioedema, a more severe form, consisting of localized, nonpitting, deep edema of the skin. 5. Anaphylactoid and Anaphylactic reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations: a) Upper or lower airway obstruction or both b) Upper – laryngeal edema causing hoarseness or stridor (lump in the throat) c) Lower – Bronchospasm generates audible wheezing, tightness in the chest or substernal pain. Other associated symptoms include dyspnea, cyanosis, feelings of anxiety (“a sense of impending doom”) d) Profound hypotension e) Tachycardia f) Severe G.I. symptoms present from onset-abdominal cramps, nausea, vomiting, diarrhea. g) Erythema and urticarial eruptions are prominent and typically involve confluent areas of the trunk, face, and neck. 6. Transfusion Reaction Acute Lung Injury (TRALI) (symptoms arise in setting of recent transfusion of plasma containing blood components [ Red Cells, Whole Blood, Fresh Frozen Plasma, Cryoprecipitate, Granulocytes], always within 1-6 hours and usually within 1-2 hours of infusion): a) Acute respiratory distress which may first be manifested as dyspnea or cyanosis b) Severe bilateral pulmonary edema and severe hypoxemia c) Tachycardia d) Fever (1-2 C increase) e) Mild to moderate hypotension, usually unresponsive to IV fluid administration f) FDA regulations require all cases of TRALI to be reported. If TRALI is mentioned and/or charted by a physician as a differential diagnosis, the Blood Bank must be notified. Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician.
  5. 1 point

    Antibody I.D. Work-ups

    Firstly kudos for taking the initiative and getting outside opinions to the changes you are experiencing and are uncomfortable with. The above comments (from way more experienced blood bankers than I) indicate your new supervisor is not wrong but needs to clarify the new process in context for you all. I suggest following AMcCord's advice and pulling some past work-ups (or invent them). Include patients with a new and previous single antibody, also patients with new and previous multiple antibodies. Then get the supervisor to walk through how he would resolve them and explain how each work-up would change with a negative and positive DAT. Running a DAT with each work-up is fine as long as it is clearly laid out what you are to do with the results and why. Once you have "proved" an antibody according to policy, running only negative cells for that antigen is normal practice because it is efficient (especially for the anti-e mentioned above). This is however assuming you have manual gel, as Dansket said only full panels can be run if automated. Hope this helps.
  6. 1 point
    I just answered this question. My Score PASS  
  7. 1 point

    Antibody I.D. Work-ups

    You didn't say how large your laboratory is and how Transfusion Services is staffed on the night shift. When I was doing manual testing, it was consistent with your new supervisor's approach. An autocontrol was only run with the first panel only. With automated gel testing on ProVue, only full panels can be run. Rule-outs are done by entering panel test results into the AntigenPlus antibody identification software. A maximum of 3 panels would be run before sending specimen to reference lab. This standardized protocol was used in a small hospital transfusion service (<1000 rbcs transfused annually) staffed with generalists. This protocol was easily followed, even with only 1 generalist on staff at night for the entire laboratory.
  8. 1 point

    Antibody I.D. Work-ups

    We start with one panel (or cells 1-10 of Immucor's Panel 20 if doing tube testing). If a specificity is apparent when crossouts are done/the pattern of reactivity is reviewed, then we use selected cells (negative for the antigen the antibody reacts with) to complete rule outs OR if a number of rule outs are needed, run another panel on the Echo. If the patient has a more complex history or the antibody screen looks more complicated, we might choose to run 2 panels on the Echo right away. I require 3 antigen positive cells which are reactive and 3 antigen negative cells which are non-reactive to 'prove' specificity. The patient is antigen typed for the specificity identified if not previously typed for that antigen and if not recently transfused. Other common clinically significant alloantibodies are ruled out with 2 cells. This works well with straight forward, single specificity samples with antibodies like anti-K, anti-E, anti-Fya, etc., which are the majority of what we see. If the antibody screen on the Echo is positive in all three cells, which happens occasionally, we run a tube/PeG screen with an autocontrol plus one panel on the Echo with some questions in mind - is it an autoantibody? is it solid phase speficific? is it multiple antibodies? is it directed against a high incidence antigen? could there be a drug involved (anti-CD38, I'm looking at you!). If the auto is positive, we do a DAT. If the specificity is not readily apparent, then we run another panel, or two, or three as needed, based on what the first panel looks like. Almost all of our IDs start on the Echo and those panels are pretty well designed for rule outs of the common offenders. It is not uncommon to use only one panel for some specificities. I encourage everyone to look at the big picture, then narrow their search based on what they see. In the long run that will save them time (and reagents). And I will admit that on a busy day, we may put 2 panels on the Echo and push GO to expedite things a bit. If we are doing tube testing, running extra panels we may not need up front, is probably going to use more time and effort. Change is uncomfortable, especially for blood bankers, but give it shot. Think the steps through and work smart. You'll start to see problem solving in a way that you hadn't seen it before. Ask your work buddies for a second opinion if you're not comfortable. Review some cases with your supervisor to really get a good feel for what he/she is asking you to do. Once you've worked through the process it a few times, you'll feel better about it. And for those ugly case - the folks at the reference lab are your best friends!
  9. 1 point

    Antibody I.D. Work-ups

    In the US we have been doing what you say is going to be the new policy for many years, except we only would do a DAT if the autocontrol was positive. I think that approach is pretty common. Orthos' panel A is for the ijnitial assessment. Most of the time, you will have a pretty good idea what you are dealing with with those results. Then, going by the 3 x 3 rule, w use other panels for rule-outs / rule-ins. Also, if there is no history, we antigen-type the patient for those antibodies that are being made. Scott
  10. 1 point
    Hi klsmith, I am now retired from the Reference Laboratory, but there is NO WAY that we would just have used red cell samples that we knew were going to be negative (or expected to be negative); indeed, if we suspected a mixture of antibodies, we would set up a cell sample for each suspected specificity, but one which are negative for the other antigen(s). For example, if we suspected a mixture of anti-D+C+E, we would set up a panel that included an example of an Ro, an r'r and an r", as well as a selection of rr cells, expressing all of the other clinically significant antigens. In the UK, we believe that any specificity should be "proved" with two red cell samples expressing the antigen giving positive reactions, and that, wherever possible, a specificity should be "proved" to be missing with two red cell samples expressing the antigens giving negative reactions. I attach the antibody algorithm I put together for NHSBT Reference Laboratories some years ago now. Antibody algorithm..ppt
  11. 1 point
    Because of the rare risk of a fatal hemolytic reaction, we only use washed group O red cells for our premature newborns. For other newborns and readmits we use ABO identical unless there is detectable maternal anti-A and/or anti-B, in which case we again use washed group O's. There is about 20-40 ml of residual plasma in almost all red cell units, more than enough to cause severe hemolysis in rare instances. We should not ignore that risk for our own convenience/inventory management/etc. in my view. We only transfuse unwashed group O red cells to patients of unknown ABO type in emergencies. There is additional evidence that ABO non-identical transfusions of incompatible antibody or soluble antigen causes harm to patients, in addition to the rare risk of life-threatening hemolysis. We have published a summary of this evidence. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600.
  12. 1 point

    ABO Retype

    To address this question of safety, I would like to see hard data from the AABB community as to the frequency of events where an ABO discrepancy was detected in the second ABO determination that was not detected in the first ABO determination. More importantly, did the detection of an ABO discrepancy (missed by the first ABO determination) prevent the transfusion of ABO incompatible red blood cells? My responses above assume that the ABO discrepancy was demonstrable by repeat testing of the first blood sample.
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