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  1. We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time ). Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well.
    5 points
  2. Back in the day, when I was working in a hospital laboratory (when Karl Landsteiner was a little boy, and we did all of our testing manually!), I never used to mind getting type and screen samples from the Accident and Emergency Department, even if the patient was not transfused in that department, or, indeed, we not transfused at all during that particular stay in hospital. The reason for this was the (approximately) 2% of people who had an atypical antibody in their circulation from a previous transfusion, a pregnancy, or both. This allowed for a bit of time to identify the specificity of any antibody/antibodies and, if necessary, ordering in a sufficient amount of antigen negative blood and blood components. Just my opinion.
    5 points
  3. If there is detectable anti-D in the antibody screen, would usually transfuse Rh negative blood, although the risk of clinically significant hemolysis is low. We do not know that mild hemolysis is benign, for one thing. As for "freshness" this turns out to be one of the things we got totally wrong. Fresher blood (<7 days say) is probably less safe for reasons unknown than blood stored 7-21 days. Fresher blood is associated with increased infections in the recipient in randomized trials, so our approach to this in our center has turned 180 degrees. We prefer not to use <7 day old red cells, but define fresh as 7-21 days. Randomized trial data. Thus in your situation I would strongly prefer 7-21 day old Rh negative red cells to giving <7 or <5 or whatever Rh positive red cells to a child with anti-D from Rh IgG. Freshness is harmful nonsense with a long history of expert opinion that, regrettably has been proven wrong by data.
    5 points
  4. The observation that antigen negative cells can yield an eluate with an antibody for an antigen not present has been known for more than half a century I believe. It's often referred to as the Matuhasi-Ogata phenomenon, first reported in the 1950s and 1960s. My mentor, Joe Bove and Patrick Mollison wrote about this a bit later in the 1970s based upon work Bove did during a sabbatical in London. Needless to say, I heard about this often as a resident physician under Bove's supervision :). Brings back memories.... Immunology,1973,25,793. Non-specificBindingofIgGtoAntibody-coated RedCells (The'Matuhasi-OgataPhenomenon') J.R.BOVE,*A.M.HOLBURNANDP.L.MOLLISON MRCExperimentalHaematologyUnit, StMary'sHospitalMedicalSchool,LondonW21PG Summary.Severalobservershavereportedthatredcellscoatedwithaspecific blood-groupantibodymaytakeupasecondblood-groupantibodynon-specifically, aneffectknownasthe'Matuhasi-Ogataphenomenon'.Inthepresentwork, thiseffectwasinvestigatedusingeither'25I-labelledantibodiesofvarious specificitiesora1311-labelledpreparationofIgGlackingrelevantantibodies.In confirmationofmuchpreviouswork,itwasfoundthatredcellstookupappreciableamountsofIgGnon-specifically;however,thisuptakewasnotincreased bypreviouscoatingoftheredcellswithspecificantibody.WhentheIgGtakenup non-specificallyincludedablood-groupantibodyinrelativelyhighconcentration, aneluatesubsequentlypreparedfromtheredcellscontainedsufficientoftheantibodytobedetectable.Thus,thefindingofunexpectedantibodiesineluatesmay beduetonon-specificuptakeofIgGratherthantoadherenceofantibodiesto antigen-antibodycomplexes.
    5 points
  5. This phenomenon is also described with the monoclonal antibody therapy anti-CD47 (Hu5F9-G4) where red cells are so heavily loaded with IgG that it creates steric hindrance. Basically, antibodies bound to the red cells hinder the binding sites of the anti-human globulin leading from very weak to negative DAT. Anti-CD47 can be eluted off the red cells and it gives very strong reaction in IAT. Of note: it is not the same mechanism involved with the anti-CD38 (another monoclonal antibody therapy often called DARA) where here the DAT can be negative too because of down-regulation of CD38 expression onto the red cell membrane.
    5 points
  6. I started doing this kind of data dig before COVID, looking at appropriateness of transfusions in the ED. Similar to you, it's usually 1 unit transfusions, often in emergent settings but not MTP. I agree with @exlimey that the shotgun approach is usually what happens, and our retrospective looking is not comparable to the ED's initial read of the patient. Most often the dreaded "hypotension" is the reason for pushing products, regardless of H/H or active bleeding. We've done education to this point with our ED, and that includes our trauma patients, that a onesy-twosy red cell transfusion for low blood pressure is not appropriate. We haven't tracked the number of TYSCs ordered, but in our concurrent reviews, these are typically ordered for patients who may be pre-surgical, or to be admitted. I feel like they order TYSCs better than blood products at this point!
    4 points
  7. Amen to the comments above. 28% is pretty good. About 5% of our patients have antibodies detectable in the indirect antiglobulin test, so we'd rather receive more samples rather than fewer.
    4 points
  8. What I was trying to get at is if the DAT is negative and the antibody screen is negative why would anyone consider it necessary to provide D negative red cells. Another thought/question just occurred to me (odd, I know), why are they transfusing the baby? Is it due to excessive blood draws or is the a hemolytic process going on? That would make a difference as well.
    4 points
  9. If @Malcolm Needs doesn't know...nobody knows. Lol!
    4 points
  10. Well, the simple answer is "YES", but whether you believe me or not is up to you. When I was the Reference Service Manager of the Red Cell Immunohaematology (RCI) Laboratory at the Tooting Centre of the National Health Service Blood and Transplant (NHSBT), we had a patient's sample referred to us from one of our samples from the East Coast of England (I have to be careful not to identify either the patient or the hospital) who had an anti-K, having never been transfused with K+ blood. However, this patient consistently had a positive anti-K in their plasma, and also, believe it or not, could have anti-K eluted from their erythrocytes, Knowing the situation (i.e. we had not supplied K Positive blood to the hospital for this patient for many years, AND knowing that they knew what they were doing - they would NOT have given K Positive blood), I was wondering if either I, and/or my staff (in their case, almost impossible, even if I was fallible) and so we sent the sample to the International Blood Group Reference Laboratory (IBGRL) for confirmation. The report we got back (from Joyce Poole) was that they also detected an anti-K, from an apparently K Negative patient with a positive DAT, but the eluate was (again, apparently) anti-K! Unfortunately, we lost track of this patient, BUT, if Joyce was a bit foxed by this case, I feel TOTALLY free to be foxed as well! Her theory was that this was a case of a "mimic-anti-K", rather in the same way of almost all WAIHA specificities being a mimicking "specific Rh antibody". Since then, of course, it has been shown that low prevalence antigens within the Kell Blood Group System can lead to "strange" antibody specificities within the Kell Blood Group System, together with weakly expressed antigens within the Kell Blood Group System. I am NOT saying this is a total answer to your query (but it is the best I CAN DO!).
    4 points
  11. Most certainly it can. There have been published papers on newborn babies being typed as D Negative, and K Negative, not because they have received an IUT, but because their mother's antibody has such a high titre that they sensitise virtually every antigen site on the cord red cells, thus causing a sort of prozone effect. The same can happen with a "blocking antibody" and AHG. It is also not uncommon for newborn babies with ABO HDFN to have a negative DAT, and be released from hospital, only to be brought in again when they become "floppy", and for the DAT to then be positive.
    4 points
  12. 28% sounds good to me, allows units to be blood type specific and gives time for antibody identification. I remember the frustration waiting for samples. I suggest asking the Dr how/if the question incorporates risk assessment for patient care and/or is it just financial.
    3 points
  13. This is a very interesting question. I suspect that many, many, many tests requested by the ED (A & E) could be categorized as "unnecessary" during analysis in the quiet time after "The Storm", i.e., the results had no relevance to the patients' treatment. But, in the moment (especially, during trauma), the medics have very little idea of what clinical data is important at that time. A "shotgun" approach seems to be appropriate. I'm not sure there is a way to meter or control this process (other than having extremely savvy ED staff). It seems to be a necessary evil - the need for rapid turn around overweighs the concern of "over-ordering" tests. And, as Malcolm says, a little extra time for the BB to do its work is always appreciated.
    3 points
  14. I would be interested in knowing how many antenatal RHIG doses the mother received. While it is possible for RHIG to cross the placenta and cause HDFN, seems to be extremely rare. The probability increases with each antenatal dose. That said, I agree with you that the baby's own cells should have sequestered any residual RHIG in circulation though I probably would not change my policy. I would just document the deviations when necessary. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877609/
    3 points
  15. Excellent use of your "abundant spare time" ! On a more serious note, analysis of this kind of data could lead to modifications in typical practice and result in efficiencies of time and money (and, ultimately, patient care/outcome). However, if the ultra-bean counters get hold of this issue, there's a very good chance that they will find, and put administrative restrictions on all kinds of "unnecessary testing". I appreciate that medicine evolves, but sometimes the appropriate approach has already been identified.
    2 points
  16. I've also seen this in an elderly K- male patient - he had never even been hospitalized in his life, much less transfused, until we saw him with his positive DAT and anti-K.
    2 points
  17. I'd look at what a manufacturer of an agitator designed specifically for platelets provides. Here is one from Helmer - https://www.helmerinc.com/products/pro-line-platelet-agitator-pf15-pro "Variable agitation speed (40-80 cycles/minute) helps meet the needs of local regulations and other specific applications"
    2 points
  18. Yes John, With higher dose anti-D immunoglobulin, the DAT of a D Positive baby is quite often positive. In the UK it is now quite common to give a dose of 1, 500 IU of anti-D immunoglobulin at 28 weeks of gestation and, as a result, many babies have a positive DAT, but I have never heard of clinically significant HDFN as a result, Physiological jaundice is also quite common in newborns, whether the mother was given anti-D immunoglobulin or not, and whether the baby is D Positive or D Negative.
    2 points
  19. I had a patient who had anti-K. He was transfused fairly regularly (2-4u/month) for years. Always K neg rbcs. Always had a +DAT. Only anti-K in the eluate.
    2 points
  20. Bottom line is believe the lab test results (data) and make clinical decisions weighing the risks and benefits :). A patient who has anti-K (mimicking, auto, passive, or otherwise) should receive K negative red cells.
    2 points
  21. Thanks for the reply @Malcolm Needs! Makes me feel a little better that something has "out-foxed" us all....including you!!
    2 points
  22. I've experienced remote alarms that were monitored by facilities crew. Even though the lab was 24/7. Facilities even did the alarm checks. Seemed to work pretty well though I had to tweak that system while I was their temp manager. Alarm probe in freezer in the air - they wanted it to be sensitive, well it was. The chart looked like a supernova explosion. I told the medical director if I was inspecting they would be tossing everything out. Once we put the probe in 50% glycerol the system worked pretty well. I still did weekly checks on the documented temps for both refriges and freezer. Otherwise, I agree, if you are 24/7 there is no need for a remote alarm.
    2 points
  23. We have the same for MTP and Emergent Release (we use 50 as the cutoff age). For routine transfusions we still require Path approval.
    2 points
  24. Our pathologists have authorized O POS for adult males and females 56 or older without requiring permission - we have this written into our MTP and Emergency Release policies. Younger females or pediatric patients would require a phone call. Since we average 25 MTP monthly, this is a tremendous help in conserving O NEG.
    2 points
  25. Not anymore.....Sadly The "bean counters" shut us down - even though our school provided over 40% of our lab's workforce.... At it's peak - ours would take up to 12 students twice a year, (Hospital Based program)
    1 point
  26. Not a Vision user, but can you use logic in your middleware/engine to remove the unwanted characters? Is there a setting in the Vision software for how the barcode is read by the analyzer?
    1 point
  27. The front and back label bar codes are identical. It maybe that when you bring the unit into your LIS system the double zeros and check digit at the end of the unit number are not used but when the vision scans the label for ABO conformation they are, thereby creating this discrepancy.
    1 point
  28. If you incorporate the main exceptions to policy into your SOP; it gives techs a clear path to follow if / when time is short or it is 3am. As you indicated it is hard to get O neg little c neg units (fresh or frozen).
    1 point
  29. I've been retired for a long time, so I'm downsizing my library. If someone wants the following books, I'll be happy to donate them. U.S.A. only. Applied Blood Group Serology. Issit. 2nd edition. 1975. Clinical and Serological Aspects of Transfusion Reactions. Judd and Barnes. AABB. 1982. Selection of Procedures for Problem Solving. Wallace and Green. AABB. 1983. Problems Encountered in Pretransfusion Testing. AABB. 1972.
    1 point
  30. Marilyn Moulds is trying to create a blood bank museum. I don't know if it is mostly virtual or not. She can be found on FaceBook these days.
    1 point
  31. Just curious but does the baby have a positive DAT due to the RhIG? Is the anti:D demonstrable in the baby?
    1 point
  32. Thanks for that. I was actually aware of this paper (I have know one of the authors, Heidi Doughty for many years - and she has my greatest respect), but you will also note that the title rather makes my point.
    1 point
  33. @Malcolm Needsas stated in my original comment............ that's just one statement from a very lengthy, detailed protocol which clearly delineates the differences......especially since we are a level 1 adult / pediatric trauma center. If we HAD TO we probably would give Rh pos to anyone......they have to live first. We can deal with the anti-D later if we have to. See attached article below - sent to our BB mgmt staff by our Medical Director. His favorite line in the whole article is, “After all, a woman cannot have a pregnancy affected by HDFN tomorrow if she dies from bleeding today”. He is currently in discussions with the "powers that be" to make a decision regarding females of childbearing potential receiving Rh positive blood in trauma.... Risk of Rh pos RBC to female of childbearing potential.pdf
    1 point
  34. I am uncomfortable with the use of the term "child-bearing age" because, if the bit in the brackets isn't properly interpreted, a four-year-old D Negative female (for example) might be given D Positive blood because she is NOT of child-bearing age, but is, of course, of child-bearing potential.
    1 point
  35. We did not. Units were kept refrigerated until they were ready to into the irradiator. We documented the time that the unit went into the irradiator and the time it came out. Electronic component prep was done immediately. If this was not possible, the units were placed back in the fridge until it could be done. I don't know what is the current checklist because I retire a year and a half ago.
    1 point
  36. No, we didn't publish as, although the case was new to me, Joyce Poole had seen this kind of thing a few times.
    1 point
  37. @Neil Blumberg yes - we are familiar with the "Ogata Phenomenon" we have seen it before and those have easily been resolved by washing with PBS rather than the "working wash" for the EluKit. This particular patient is not resolved - making it a bit of a mystery outlier.
    1 point
  38. Why would you want to transfuse blood at such a high rate? Perhaps I'm misunderstanding, but I would never transfuse a patient who wasn't exsanguinating at 300 ml/min. And having that level of flow isn't necessary for transfusion, so I'm a bit clueless about why you picked that number. It's a dialysis issue, not a transfusion issue, no? Vascular access is not the transfusion service's purview, in general, so I'm not clear why you are concerned. Have you had lots of red cells returned because they didn't have vascular access?
    1 point
  39. So, why, pray tell, does the alarm even sound at a nursing desk? This is quite unnecessary and obviously inconvenient for all involved. If the reason is, as usual, "that's the way be been as long as anyone remembers", it's time for a change. Hopefully you can get this easily rectified. Good luck.
    1 point
  40. If this is the case, I would propose you do not need remote monitoring.
    1 point
  41. Bet'naSBB

    Eluate last wash

    @AuntiS - as far as running the last wash with A1 and B cells - my thought is that it serves as a negative control for your possible (although VERY unlikely) ABO specific antibodies that may be left. We run a panel and A1, B cells with ALL our eluates except cord blood eluates. For them we run screening cells and x3 A1 or B cells depending on mom/baby ABO incompatibility (we prefer rapid acid over LuiFreeze for cord bloods) For our last washes we run screening cells and A1,B cells In the end it comes down to how the protocols are written for each facility.
    1 point
  42. That has always been my impression as well. On a related topic, the u in Du stands for Underwood. The first patient who was discovered (or at least the first one written up) was named Underwood. Frances Wideman told me that at a CAP Transfusion Medicine Seminar ages ago.
    1 point
  43. exlimey

    Paperless QC entry

    I agree. I like the blue ink option because it used to be an obvious indication that the document is the original. Now, with color photocopiers in widespread use, I have to double check. Sneaky !
    1 point
  44. Ensis01

    Paperless QC entry

    I like the not black or red ink logic; all other colors clearly indicate an original document and not a photocopy. As long as it is permanent and waterproof any other color or shade of ink works. I personally like weird blues
    1 point
  45. In the UK, unless a piece of work (such as running positive and negative controls) is signed and dated by the person carrying out the work, it is regarded as not having been done in the first place. While I am not, by a long way, in favour of everything suggested by either "Internal Quality", or "External Inspectors", in this I stand four square with them. On the other hand, when they prescribe what colour ink we should use, they can go take a running jump, as far as I am concerned.
    1 point
  46. My Medical director wanted/authorized Rh pos to all during massive transfusion protocols. That made a huge difference in conserving Rh neg and especially Oneg.
    1 point
  47. Basic guideline from our trauma center-- O Pos to all males and females over 50 Critical shortage--use O Pos. The Medical Director can sign after the emergent event
    1 point
  48. Just because an antibody is avid, it does not mean that it is high titre; the two are not identical.
    1 point
  49. Thank you very much Malcolm. I'm going to read this over again at home - maybe with a cold beverage in hand - and let it sink in. I appreciate the time you take to answer these questions and my student will be very pleased with your compliments.
    1 point
  50. The simple answer is - yes, pretty much. You must assess all 6 elements for each 'test system' every year. How you do it is where is gets complicated. I assess each tube test (crossmatch, blood type, DAT, antibody ID, etc., plus 'automation' (rather than each individual automated test but would include tasks related to preparing specimens for testing, processing tests, through resulting). I also assess problem areas and some none test related skills (like packing blood) in more detail. Remember that you can cover a lot of ground during observation by asking questions (which cover trouble shooting plus knowledge of procedures), asking them to do QC testing related to the test performed, documentation, etc. It is very time consuming and I would love to hire someone to do it, but that's not going to happen. I have some kits I get specifically for competency assessment that require tube blood type, antibody screen, ID, antigen typing, and crossmatch. While the tech is doing the exercise they perform all the necessary QC plus documentation and I ask them questions about what they are doing and how they decide what to do. That all by itself covers a whole lot of ground. If your budget doesn't allow purchasing kits, make your own samples up with all patient samples and reagents. While they are incubating, I throw in DATs on samples I make from check cells and cord bloods with positive DATs and fetal bleed screens (use positive and negative controls from old kits for sample manufacturing). Once the kit sample is worked through, we've gone a long ways toward finishing the assessment. Depending on how fast my techs work and what they are cleared to do, it takes 4-8 hours to do observations for each tech. I also do ongoing review of documentation, QC, etc to assess what they are doing when I'm not looking...this is part of what I'm looking at during supervisory review. If/when they handle a difficult situation during their routine shifts, I review the records to see how they handled/solved the problem and ask questions as needed, all of which can be part of competency assessment. Everyone rotates through surveys. These are ordered in our LIS like any other patient sample so I use that work for additional assessment of documentation, problem solving and computer skills. Remember that if there is a problem uncovered during your assessment, you should be sure to document the action plan for 'fixing' the problem plus documentation for reassessment to prove that the problem was 'fixed'. (P.S. I work on the bench a large percentage of my time as the only full time blood banker with lots of generalists, so I do understand what an obligation this all is. I just focus on the task at hand and try to keep moving. If I look at the mountain, it is overwhelming.)
    1 point
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