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  1. Malcolm Needs

    Malcolm Needs

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  4. John C. Staley

    John C. Staley

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Showing content with the highest reputation since 08/21/2021 in all areas

  1. Malcolm Needs

    A1 lectin QC

    I attach a hybrid of my lectures on the differences between the A1 and the A2 ABO type, together with a very few slides from my lecture on lectins, and I hope that this will serve to be of some use to you. It is hugely important to remember that many lectins, including Dolichos biflorus, are not specific unless they are diluted to ensure that they only react as desired. For example, this particular lectin (Dol b) will react quite strongly with A2 red cells unless suitably diluted so that it only reacts with A1 red cells. It is because of this that group B red cells are totally unsuitable to be used as the negative control for the Dol b lectin, and the same applies for group O and other group A subtypes. Group B red cells will not tell you whether or not your grouping reagent is "specific" for the A1 antigen, or will still react with the A2 antigen. In addition, the lectin will also react with red cells expressing the rare polyagglutination antigens Cad and Tn, and so, in the true meaning of the word, it is not "specific" anyway. What is the difference between A1 and A2.pptx
    5 points
  2. I suggest to my techs during training that it may be prudent to test the last wash before preparing the eluate - especially when additional red cells are not available. I'm sorry to report that I have seen several elutions where the last wash never became negative..... usually with cord cells where the mom had a VERY strong antibody - even changing tubes with every wash. I'm sure that if I had had the patience and persistence, it might have become negative but I gave up at 10 washes.
    4 points
  3. I agree entirely that this process is not efficient working in a busy Blood Bank, or any other sort of Blood Bank. There a re many occasions when a patient can wait for the next transfusion, whilst various tests are performed, but we, as Technicians/Biomedical Scientists (or whatever else we are called around the world) are not in a position to "call the odds". We MUST react quickly. Granted, most of these tests will be "false alarms" (or so I would hope!), but when the test is genuine, it is necessary to react quickly. The clinician needs to know, and so does the person working in the laboratory - THEY have got to get antigen negative blood available pretty damn quickly, while the clinician is sorting out the acute haemolytic transfusion reaction. If it is a query delayed HTR, given that in most cases the patients are transfusion dependent (and, therefore, venerable - or even vulnerable!), why take the risk?
    4 points
  4. Run side by side. Does your SOP, or manager (or anybody for that matter) give a reason why it is eluate first then Last wash? It would make more sense for a policy to state run the last wash prior to the eluate (especially if there are few red cells) to ensure sufficient washing.
    3 points
  5. Something to consider. If the charge drops at XM you might get paid for it. If it drops at transfusion and the blood does not get transfused you will definitely not get paid for the XM. Something to think about. We dropped the charge when the XM was completed. Another little story from the past. Us old guys like little stories from the past. I was called to the billing office to "discuss" a billing issue with someone from the insurance company. She wanted to know why we charged for the XM when no blood was issued or transfused. I told her that the DR. had ordered the testing in the anticipation of needing the blood because the surgery routinely required transfusion. We did the work and charged for it. Her contention was that since the patient did not use any blood the testing was unnecessary! At about this time I asked to see her license to practice medicine. She became quite incensed when I told her that insurance companies had no business practicing medicine. That's when our conversation came to an abrupt end.
    3 points
  6. BioRad service engineers do not wear running shoes either...they stay as long as needs be to ensure that the machine is running smoothly without glitches. Can't say that for others who seem to have boarded the first flight on holiday before a batch of samples have completed the running.
    2 points
  7. Sorry - just saw this reply now. Canadian Blood Services tests all donor units for K. If K negative, the donor end label has K- on it. If K positive, the end label doesn't have any K antigen testing information listed - the K+ status is only embedded in the donor unit phenotype barcode. All donor units are treated the same - so the K+ units are available, as all other units are, but it is easy to select a K- unit for females of childbearing potential and who are on a drug like daratumumab. sandra
    2 points
  8. Having had the opportunity to have worked with all 3 of the aforementioned machines, I'd say beyond any doubt that Biorad is light years ahead of Ortho. You get definitive results with Biorad, not the untold and innumerable false positives using Ortho reagents and products. I don't remember having any major downtime issues with Biorad apart from the expected wear and tear of a robust machine running 24/7 - 365. The turnaround time using Biorad was much better. Maintenance schedule is a breeze.
    2 points
  9. Cliff

    Blood on Helicopter

    Hi John, We bill them for the products. If the RBCs are retuned, there is 0 charge. No charge for any service or processing on our end. As I mentioned, we bill for all liquid plasma as it's not a product we transfuse in the hospital, and we don't want it returned to reduce the chance we use it in error. They bill for the transfusion. BMF is an unusual setup, they are a consortium funded nonprofit. We're one of the hospitals that funds them. Thanks
    2 points
  10. I have always run the eluate and last wash in parallel, but the question did make me think. I appreciate the attempt to reduce (potentially unnecessary) work, but don't like the idea of doing two-stage testing (eluate first and then Last Wash, or the other way around). If this happens, you've lost any efficiency (and time) you believed you gained by not testing the eluate and Last Wash in parallel. However, the cautious approach to a low volume (rare) specimen may have some merit - checking the Last Wash first adds confidence that any eluate prepared from the washed cells will be more likely to be valid. The two-stage testing concept has crept into the laboratory over the last couple of decades and is completely valid for follow-up or reflex testing. But.....one of my peeves: Reagents that suggest "Immediate spin, incubate negatives". If you're running a negative control anyway and/or most of your tests will be negative (DATs with anti-Complement reagents), you'll almost always be incubating, so why bother with the Immediate Spin ? Bottom line: Do what the eluate kit manufacturer says (unless you've validated otherwise).
    2 points
  11. O.R. has forever been, and forever will be the weakest link in transfusion services. As was previously stated, there are a lot of moving parts and many of those vital parts have no computer access since they are contracted workers. For instance, the perfusionists and anesthesiologist have no computer access since they are only here for the case. All orders are verbal orders. They are the ones starting and ending the transfusions. There is no computer in the suite, everything is done at the desk by the circulating nurse. We have fought for decades to change that process but have had no success. Everything is manual in O.R.
    2 points
  12. Emelie

    Oldschool

    Found this old gem while cleaning out our retired doctor´s office. It´s Claes Högman, a real giant in Swedish blood banking, who (among other things) was a delegate in AABB during the 60's and recieved the Karl Landsteiner award, James Blundell award and the ISBT award. He sang in the Uppsala band "Blodsbandet" (transl Blood relations) under the name "Captain Blood". The song on the tape is "Give blood! Mr Sagman", which I suspect is a cover of "Mr Sandman"... Enough written, now I've gotta go find a cassette player!
    2 points
  13. Malcolm, I agree this was truly insensitive and arrogant behavior, not atypical of physicians in many periods of history, granted. I do believe this is very different from our use of about to be discarded cord blood specimens used for laboratory testing, but I'm sure some would disagree. Our human subjects review boards generally consider laboratory testing blood specimens from patients that would otherwise be discarded may be used for research purposes or quality control purposes without informed consent.
    2 points
  14. Oh, how agree with your comment. Mind you, it must be remembered that this was all caused by doctors (mostly histologists, if I remember correctly) who kept parts of babies, without asking for the permission (or telling) the bereaved parents.
    2 points
  15. We have yet to see a patient on daratumamab who has made an anti-K antibody after years of transfusing red cells without regard to K antigen status. We use cord red cells in an antibody screen to rule out significant antibodies to allogeneic red cells (they are CD38 negative) as our method of dealing with this issue of pan-reactivity from daratumumab. I know this practice isn't allowed in the UK due to the over the top regulations that followed the infant parts kerfuffle. We detect plenty of anti-K's, just NOT in patients receiving anti-B cell therapies. In fact, I cannot recall a single new red cell alloantibody in myeloma or lymphoma patients receiving daratumumaub, rituximab, etc. No B cells equals dramatically reduced risk of alloimmunization, so you may be worrying about something that is pretty unlikely to happen. Just another approach.
    2 points
  16. It would be really useful if you could tell us the ethnicity and age of the patient, and his medication regime. That having been said, I note that the antibody screen is positive, that his DAT is positive by both anti-IgG and anti-C3d, that the neat plasma contains an apparent anti-E and anti-c, but that the eluate contains an antibody that is, apparently, pan-reactive. Very often in these cases, the apparent antibody specificity in the neat plasma is a mimicking specificity, rather than a true specificity. In such cases, the apparent specificity in the neat plasma can be adsorbed out using red cells that are negative for the antigens of the apparent specificity; in this case R1R1. The true specificity of the antibody could be an anti-Rh17 or anti-Rh18. While I am not saying for a single second that the apparent specificities of anti-E and anti-c are not true specificities, it may be worth your while seeing if they can be adsorbed out using R1R1 red cells. However, as you suspect the presence of other antibodies, this should not be attempted until you have proved otherwise. This you can do, as you suggest, by alloadsorption of the neat plasma using two or three adsorption cell types. In answer to your last question, with regard to adsorption of the eluate, this was certainly a method we used in the Reference Laboratories of the NHSBT in the UK. It was usually used when the patient had a known pan-reactive autoantibody, but was requiring transfusions more frequently than previously, and/or when the expected rise in the haemoglobin concentration was not achieved. On some occasions, we were able to detect a de novo alloantibody in the eluate that we could not detect in either the neat plasma, or the adsorbed plasma, although this was not always the case, as transfusion in and of itself can sometimes stimulate the autoantibody to become more active (see Petz LD, Garratty G. Immune Hemolytic Anemias. 2nd edition, 2004, Churchill-Livingstone). Good luck with sorting it out, but this is a really interesting case. Thank you for posting it and, please, would you mind letting us know how you get on?
    1 point
  17. OkayestSBB

    A1 lectin QC

    Thanks Malcom! I know A1 lectins need to be diluted properly but didn’t think it all the way through to that’s why A2 cells are a necessary negative control.
    1 point
  18. having been a manual gel user for years I am switching to solid phase in the next few weeks (ECHO 2.0). I like the fact that it's pretty much hands off once on the instrument. I wanted to get away from gel as I've experienced many of the same discrepancies as with tubes. I expect this will have its own vagaries however it is a step up for my staff. Also the price was right for a refurbished unit.
    1 point
  19. Cliff, my 1st thought was to ask, who handles the financial aspects of your process? In other words who charges who for what concerning any blood transfused by the helicopter crew? What made me think of this was when you mentioned that BMF sold the plasma to a fractionator instead of returning it.
    1 point
  20. Cliff

    Blood on Helicopter

    We were the first to provide helicopter blood in MA. It was a long process, but we've simplified it as much as possible. Our primary supplier in MA is ARC. They would not perform the ABO / Rh retype for Boston MedFlight (BMF). The products come to us. We went with O Pos RBCs. We have our own donor center but are not licensed, so chose to get them irradiated from ARC as they will travel outside of the state. That was OK for a couple of years, then we started adding bases and liquid plasma. We contacted FDA and learned we were allowed to irradiate the plasma, so they now have that too. We worked very closely with BMF in setting up their program, they were the greatest bunch of people to work with. They have a blood bank fridge and freezer at each base and are using Credo coolers. We worked with them to perform validations on the products stored on the ground and air ambulances. All coolers maintain temp far past 12 hours. They swap out the coolers every 12 hours. We were concerned this might be considered storage more than transport, so they now monitor all coolers 24/7. They have Wi-Fi on the helicopters. They return the RBCs if they get too close to their outdate. The plasma we do not want back as we do not use this product in our hospital. They sell it to a fractionator. We've been inspected by TJC since we've gone live, and the survey went fine. We had a virtual inspection with FDA in July, no comment as of yet. AABB chose not to go out to any of the bases. They have transfused a lot of products making this a very successful program.
    1 point
  21. applejw

    Blood on Helicopter

    I can describe how it works for our healthcare system and PM a copy of our policy. The pre-hospital transfusions on the helicopter pre-dated me at this facility but I have expanded to ambulance pre-hospital transfusions on 3 ambulances with begging to increase to 4 ASAP. We maintain sets of 2 O NEG RBC and 2 low-titer liquid Group A plasmas for 1 helicopter and 2 ambulances that work out of the level 1 trauma center. We set up a dummy patient for each vehicle and units are pre-labeled for that dummy patient, segments are retained at the Blood Bank, each unit wears a Saf-T-Vue10 indicator and a triplicate Emergency Release form with unit numbers documented on the form with one copy of the form retained in the Blood Bank to keep track. Each vehicle uses the Pelican Biothermal Credo and changes out each blood product set once every 24 hours. The crew at the vehicle base is responsible for exchanging the cold panels for the credo. Each credo carries a datalogger and the datalogger report is downloaded and emailed to the Blood Bank at least weekly for review. Each credo is validated to maintain temperatures for up to 3 days prior to being released for active use. When a patient is transfused, the flight/medic crew is responsible for returning one of the copies of the emergency release form signed by the crew's MD to the originating Blood Bank and one copy goes on the patient's chart. Units are released from the dummy patient, crossmatched (if we get a sample), and transfused in the LIS to the actual patient. The crew returns to their base to replenish the units that were transfused. If the patient is transferred to a hospital that isn't part of our healthcare system, we still have a copy of the form returned to us and the crew will tell us where the patient was transported to and we "transfuse" the dummy patient with unit comments in the LIS with whatever information we received from the crew .
    1 point
  22. I work in a San Antonio hospital and what was reported at AABB was the expectation. It is NOT the reality. First, all units supplied to the ambulances and helicopters come from our regional donor center. No hospital transfusion service provides the units nor are we responsible for the disposition of the same. All of this is monitored and tracked by the regional donor center and the EMS. What is supposed to happen is, when a patient has been transfused en route, the completed unit and EMS's transfusion form is supposed to be sent to the blood bank upon arrival. This almost never happens. The only way we know in the blood bank is when we get mixed field reactions on our blood type or by reading physician notes on the chart. I read the physician note of every emergency release. That is how I normally find them. The physician will dictate that the patient received blood in the ambulance. It takes days for me to track down the paperwork and the empty bag is long gone by then. We NEVER crossmatch them because we never receive them. All that said to say, your helicopter company needs to contract with whomever your blood supplier is to stock the units. That should not come from the transfusion services department of the local hospital. You might serve as a pass-through site, meaning the donor center uses you as a pick-up point but the units are never part of your inventory.
    1 point
  23. In my opinion, you can run an antibody screen on the last wash instead of a full panel. Of course if the screen is positive, you'd want to run a full panel. I have never known the last wash screen to be positive.
    1 point
  24. That sounds like an absolute logistical nightmare. Maybe I have missed something but I have visions of coolers being left in the helicopter, on the helipad (winter and summer), in bathrooms and forgotten in corridors etc.
    1 point
  25. I'm just curious but what do you weigh on this scale that would make a range of +/- 5 gms unacceptable?
    1 point
  26. I tend to work them the way "galvania" works them too. I just start with the high frequency antigens and work down to the low frequency ones. That is the way we screen too - eliminate the high frequency antigens and screen only the negative units for the lower frequencies as you get to each antigen. (mostly we just call our distribution center (Vitalant, El Paso) for units like that - they are doing an outstanding job getting units for the "messy" patients!!)
    1 point
  27. I just answered this question. My Score PASS  
    1 point
  28. I just answered this question. My Score PASS  
    1 point
  29. I don't think the XN will allow you to run without the WNR reagent. You wouldn't be able to get an automated differential because the basophil count comes from the WNR. Also, the NRBCs come from the WNR channel, so any WBC count from the WDF channel would also include NRBCs.
    1 point
  30. I just answered this question. My Score PASS  
    1 point
  31. Or was the K_B positive because mum had high levels of HbF and therefore none of the injected anti-D 'used up'?...... Butlermom - where are you??????
    1 point
  32. We require the RNs (or another aide) to bring a small pickup slip with the patient admission label on it. This label includes the pt's full name, MR# and Acct# (financial #) and the BB ID band number when they are picking up RBCs. We do not require a BB ID band # for plasma transfusions. They also must bring a copy of the current "consent to transfuse" form - filled out correctly. Outpatient RNs bring a copy of the transfusion order and the consent form - with the Pt's BB ID band # if picking up RBCs. O.R. is required to bring one of the small pickup slips with the Admissions label and and the BB ID band # if requesting RBCs. They are not required to bring a copy of the consent form. E.R - in an emergency situation, uses an Emergency Release form (handwritten by us) based on information in the computer or that the E.R. fills in. They do not have to bring a consent form until everything is caught up and the TS is completed and the pt is off Emergency Release protocols. Because we still use and require a unique BB ID wristband for blood (RBC) transfusion - both the floors and the O.R. have to prove we are all working on the same patient. Until we get some kind of system that fewer people (I won't say none!) can screw up - I prefer the use of an independent BB ID wristband where the Draw - to XM - to Transfuse circle has the best chance of not being corrupted. We also require a second specimen (independent draw) for all ABORH confirmations. Doing the best we can to not make a mistake.
    1 point
  33. The most I've ever given postpartum is 7. C section delivery with a great deal of placental manipulation.
    1 point
  34. I agree entirely. I found it really difficult sometimes, when, for some reason best known to themselves, a Blood Transfusion Consultant in a Hospital would insist that we performed a titre and/or a specificity on a cold auto-antibody, rather than just the thermal amplitude (as advised by Petz and Garratty), and I had forage around in our freezer for extremely rare Adult ii red cells, rather than using an otherwise discarded cord sample. It is utter madness.
    1 point
  35. I understand now, had to read the thread over again and the reasoning with my simple mind. Well if the patient's antibody screen was negative prior to Darzalex treatment, then given K neg units once the antibody screen was affected by the DTT technique, then I can understand how giving 'regular' units once the antibody screen is negative would be acceptable because none of the units given would have caused that immune response (Aha moment). duh. Thanks everyone.
    1 point
  36. I will also play "Devil's Advocate" then. Where on Earth are people finding all these units of blood that are Ko (which is what Kell Negative means), and, on the other hand, if you are going to give K-, k+ units, how do you know that the patient isn't a K+k- individual, with an anti-k? Why not KEL genotype the patients (and I don't mean a full gene sequence) and give "matched-blood" for what the test predicts the antigen expression?
    1 point
  37. My two penneth for what it's worth; when the patient is in the OR the anesthesiologist determines blood product requirements (often by verbal order) so all an OR runner needs is name and MR#. It seems your, very valid, concern is avoiding WBIT from the outset due to the issues you outlined above. I suggest the solution is that the OR processes need to be cleaned up (literally). Therefore get QA involved. I am not a manager so others here will be way better at giving suggestions on how to proceed down that path and ensure changes are made, and just as importantly maintained.
    1 point
  38. There is a pick up slip that can be printed out of Epic. It is a blood requisition form. We also have a downtime form that nurses use when Epic is down. I am attaching the downtime form Blood Product Pickup Form - revised 10.29.20.docx
    1 point
  39. I need clarification. I once asked on this site that if you could not rule out an antibody could you 'ignore' it once your screen is negative and I believe the answer was no. If in these cases with Patient's going off Daratumumab, if you could not rule out Kell (due to DTT treatment of cells), even once, don't you have to consider that a permanent problem even though we know that the probability that an allo anti-K developed is probably null?
    1 point
  40. We do the same. Ours is setup to print the transfuse order both to the blood bank and to the nursing printers.
    1 point
  41. ..........and on the result of the reagent control you put up with it and what is wrong with the patient, if it's a man or a woman,and how old................and why you were doing the test in the first place
    1 point
  42. The nurse's "transfuse" order can be turned on to print when released. That is what our nurses bring to us out of Epic for blood pickup. The patient label is the downtime procedure for when the printer isn't working or for surgery patients because that workflow does not use transfuse orders.
    1 point
  43. I know that some of the early work on ABO-mismatched solid organ transplantation, viz-a-viz ABO antibodies was carried out by Professor Patrick Mollison and his co-workers, and he showed that, whereas inhibition of IgM ABO antibodies is reasonably easy by, in the early days, transfusion of FFP to adsorb the antibodies in vivo, the same is not true of IgG ABO antibodies. He and his co-workers found the inhibition of these antibodies was much more difficult, and this was almost certainly because only 40% of IgG antibodies are intravascular, as so they "rebound" when inhibited or removed from the intravascular area, whereas almost all of the IgM antibodies are intravascular, and so "rebound" is less likely.
    1 point
  44. This is interesting. We had the Emergency release order placed/signed by the physician in Epic. FDA inspected sited that the physician signing and order wasn't enough because we had to also include the clinical reason the blood was requested and the AABB statement. I added order questions in epic with answers like "acute blood loss" but in the end we opted to just keep the paper form to avoid any more scrutiny from FDA.
    1 point
  45. I don't know if this will help or not. I talk a bit about anti-D prophylaxis towards the end, and why it sometimes fails. If it doesn't help, just ignore it!!!!!!! In Depth Lecture on Alloimmune Haemolytic Disease of the Foetus and Newborn HDFN.pptx
    1 point
  46. UK units are all K typed. We don't give K+ blood to females <50years, children, anti-CD38 patients, chronically transfused (eg Sickle) or anyone with anti-K. Anyone else is fair game.
    1 point
  47. Just curious.....what does the system do with those potentially immunogenic K+ units (donors) ?
    1 point
  48. At my previous hospital we would accept and use a historical ABO from another lab but only if it came from within our hospital system.
    1 point
  49. I prefer to start with more cheaper reagent.
    1 point
  50. Assuming you don't want to count the frequency of B or O and just want to know how many B or O neg units you need to screen it should be 0.34 X 0.25 X 0.9 X 0.99 or so (frequencies from memory) which gives you 7.5%. If you screen about 15 units, you should find one--unless the blood supplier has kept all of those negative units or you have bad luck. Statistics don't hold up well for small numbers so you might screen 30 before finding 1, then will find 3 in the next 30. Hope I got that right.
    1 point
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