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I have to ask, how many times when the DAT is negative and you can elute the antibody from the babies cells does the infant show symptoms of a significant case of HDN (old guy, old nomenclature) resulting in an exchange transfusion or even phototherapy? Seems to me you are doing an awful lot of work for little, if any, benefit. See Malcolm's technical discussion above.

We will draw blood is the patient is receiving a transfusion. We put a comment on the results stating the patient was being transfused at the time of draw. We will draw a patient 15 minutes after transfusion. Here is the reference we used for our policy. Elizalde, J.I., Clemente, J., Marin, J.L.,Panes, J., Aragon, B., Mas, A., Pique, J.M., Teres, J. "Early changes in hemoglobin and Hematocrit levels after packed red cell transfusion in patients with acute anemia." Transfusion Practice. Volume 37. (1997): 573.

We use a training/competency sign off initially. Then follow up at 6 months and one year with repeat competency assessments. I think that you need to have documentation that training has been completed satisfactorily, which is best demonstrated by an acceptable performance on a competency assessment. The individual may not be performing at as a high level of competency as they hopefully will be at 6 months or a year, but they should demonstrate a minimum level of competency, as determined by your facility, before performing patient testing.

One thing I would say is that the baby should be treated on clinical symptoms, rather than on laboratory results, particularly when they are so weak that you have to do all this testing to show an abnormality in the Blood Bank. A slight rise in bilirubin is normal in a newborn baby. This situation is very similar to the difference between a haemolytic transfusion reaction, where, for example, there is a positive DAT, antibody can be eluted and there is a SIGNIFICANT rise in bilirubin and a SIGNIFICANT drop in Hb, and a serological transfusion reaction, where there may, or may not be, be a positive DAT, antibody may or may not be eluted from the red cells, a new antibody specificity may be detected in the plasma, but there is NO SIGNIFICANT rise in bilirubin and NO SIGNIFICANT drop in Hb. Your cases remind me strangely of the latter.

Partial DVI is the single most common partial D found in the White populations, having a phenotype frequency of between 0.02 and 0.05% in these populations. Have a look in Daniels G. Human Blood Groups. 3rd edition, 2013, Wiley-Blackwell and/or Klein HG, Anstee DJ. Mollison’s Blood Transfusion in Clinical Medicine. 12th edition, 2014, Wiley-Blackwell. You will find several references in either or both of those books. Alternatively, look for http://www.rhesusbase.info/ in your search engine (which is a superb site). It is only really necessary for the "donor side" to look for individuals with Partial DVI. There really is minimal evidence (even that is stretching it) that foetuses/babies who are Partial DVI can cause their D Negative mother to produce an anti-D, but it would be almost impossible to put that particular genie back in the bottle! That having been said, in my experience, the moment that people find that the baby is a Partial DVI, they shoot the mother full of anti-D immunoglobulin, without ever testing the mother to find out if she is also a Partial DVI. One day, a virus, unknown at present, will be passed on in the anti-D immunoglobulin, and it will be proved that it need not have been given in the first place, and then, all Hell will be let loose.

We do. We use plain clear zip lock bags. We have used biohazard bags in the past. We stopped because there was a concern that the patients might think we were giving them biohazardous units.

We use plain old plastic ziplock bags. Not so much for the safety of the transporter but in the event they drop the bag and it happens to break.

We see a positive DAT from time to time that we attribute to RhoGAM, but no indication that any of these babies had elevated bilirubin levels from the anti-D immunoglobulin. There are a number of physiologic reasons for elevated bilirubin in neonates. If mom is a smoker, they have a lot of red cells on board that they don't need after birth. As Malcolm says, they are switching to HbA production. If the baby is not hydrated well the bili can become elevated, Etc... If anti-D has been identified in mother's sample and can be reasonably attributed to antenatal RhIG, we don't perform a titer on Rh positive baby cord blood samples unless there is some indication that something else is happening (strongly positive DAT or unexpectedly high bilirubin).

We have had Routine Antenatal Anti-D Prophylaxis (RADDP) in the UK since August 2008 (National Institute for Health and Care Excellence (NICE). Routine antenatal anti-D prophylaxis for women who are rhesus D negative. Technology appraisal guidance (TA156). Published date: 27 August 2008) - please excuse the word "rhesus"; they were told about this before publication, but they ignored all advice. The following quote is from Qureshi H, Massey E, Kirwan D, Davies T, Robson S, White J, Jones J, Allard S. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine 2014; 24: 8-20 (doi: 10.1111/tme.12091), "A direct antiglobulin test (DAT) on the cord blood sample is not routinely performed since it may be positive in a proportion of cases because of antenatal prophylaxis with anti-D Ig. However, a DAT should be performed if haemolytic disease of the newborn is suspected or anticipated because of a low cord blood haemoglobin concentration &/or the presence of maternal immune red cell antibodies." From this, it can be seen that the phenomenon you describe is far from unusual, and extensive trials went on as far back as the early 1960's (Finn R, Clarke CA, Donohoe WTA, McConnell RB, Sheppard PM, Lehane D, Kulke W. Experimental studies on the prevention of Rh haemolytic disease. British Medical Journal 1961; 1: 1486-1490. doi: http://dx.doi.org/10.1136/bmj.1.5238.1486, and no evidence was found that the fetus or newborn would be affected by this passive anti-D, even with a slightly raised bilirubin, which, is normal anyway, as HbF production is "switched off" and replaced by HbA production.

We keep RBC and plasma on our helicopter using the Pelican Credos and a datalogger. Units are changed out every 24 hours or replaced when transfused and they keep extra sets of credo panels in the ER freezer to follow manufacturer IFU. Dataloggers record temperatures every hour with an audible alarm to the user if the temperatures exceed 6C. Datalogger data is transferred to the Blood Bank for review and retention. We are looking into keeping units with supervisor units for ground transport in 3 counties but that is still in the works. If you can install an undercounter BB refrigerator at the airport with Wi-Fi temperature reporting and 7-day continuous chart recording, that may be another route to investigate. I have worked at a facility with remote storage at the heliport that was maintained by both ARC, hospital and air ambulance services. All have to work together to meet requirements to ensure that blood products are maintained properly.

As long as you validate/verify the digital, I believe annually is the requirement, you should be fine without a second thermometer hanging around waiting to get broken.

Nursing policy for blood administration should include those type of guidelines, They have references available for infusion rate, etc. The medical director of blood bank should (ideally) then review all of those polices to make sure that what they have included is good practice. In other words, a collaborative procedure. We struggle with getting blood/blood product nursing policies reviewed when written. There is a constant rotation of new nursing admin staff writing policies who never seem to know that our medical director should review those new policies and they don't understand what the lab has to do with administration. I just tell them it's an FDA requirement and TJC expects those requirements to be followed. Our nursing policies are accessible on-line so I search periodically for blood related policies to see if anything has been added. I put all of those policies in my SOP manual under blood administration. When I do biannual review, I check to see if the policy has been revised so I can upload a new version if necessary. I usually check at least annually as well. The policy format used by my facility assigns 'ownership', which is the VP of nursing, 'authorship' and also includes a line which indicates people who must review the policy. TJC requires policy review every 3 years, so that's why I include those policies in my manuals - to make sure they are reviewed often enough for CAP requirements. If I find a policy that does not have the medical director's name on it as a required reviewer, I reach out to the 'author' or the 'owner' to see about getting it added. I've also made a point of knowing who is responsible for the facility policy manuals and who is responsible for the Joint Commission compliance book. I have those 2 ladies on speed dial and they are very helpful. It can be painfully slow to deal with all the committees/councils that direct nursing policy. I tell myself that persistence and patience is key (and patience is not necessarily one of my virtues!).

We supply blood to a helicopter service with a contract with our hospital system. We put Safe-T-Vue indicators on all of their units. They provide us a copy of their in-flight chart when they transfuse anyone not coming to our hospitals. If the patient doesn't come to us but has an account in our HIS, we create a bogus registration in our BBIS using a defined format account number. If they don't exist in our HIS, we create a complete registration manually in our BBIS using a defined format for MR# etc. Then we emergency issue the product in our BBIS and handle it just as we would those patients who expire before a specimen is drawn etc. We charge the helicopter service for the products which they include in their flat fee to the patient. We maintain the final disposition records for any lookbacks etc. If we got a market withdrawal or lookback, we would notify the helicopter company to follow up with the recipient. That duty is at least vaguely covered in our agreement with them, I believe. We tell the helicopter crew to return any unused products to us and not to leave them at the receiving hospital but this isn't perfect. We sometimes transfer products on paper to the receiving site if we can document handling sufficiently. It doesn't work easily if the receiving hospital doesn't use the same blood supplier.

Agree with the comment above. While the patient is in your chopper with your blood, it's your patient. Somehow you must be be charging for the ride and any other care in flight. And like any unit transferred with a patient to another facility, you will have to follow up to finish the transfusion record. Scott

We do not recommend infusion rates. That is the purvue of the ordering MD (anyplace I have ever been). The only thing I tell nursing is to infuse plts as quickly as prudence dictates.

I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs. Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive. Then everyone else is scattered around in between these 2 extremes. Then throw in the males and women who are beyond child bearing and it becomes even more complicated. I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.

We have a policy to offer RhIg if we have given Rh Positive Random Donor Platelets to an Rh Neg female of childbearing potential. The amount of RBCs in a platelets is normally less than can be covered by a single dose of RhIg unless the platelets were particularly bloody in which case we don't accept them from our supplier. Luckily these days our supplier is doing a great job of supplying only Single Donor Platelets so bloody platelets are not an issue. Giving enough RhIg to cover a RBC transfusion would not be a reliable or economically feasible option since the RhIg we have on hand only covers 15mls pRBCs. So a one (1) standard unit of packed RBCs would take in excess of 18 doses. As Malcolm said giving the RhIg would have the added downside of clearing the Rh Pos RBCs you just gave so unless you have additional Rh Neg units available you are just putting yourself behind again.