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If current antibody screen is positive and Lewis antibody identified, do immediate-spin and anti-igG crossmatches, issue crossmatch-compatible random donor units. If current antibody screen is negative and there is a history of Lewis antibody, do Computer Crossmatch with random donor units.

I would just like to add one 'grain of salt' to this debate. You cannot detect all D variants - whether D weaks or partial Ds by serological methods alone. Neither D weaks or Partial Ds behave in a way that allow one to say that all D weaks or partial Ds react with such and such a strength. You will always miss some. You will miss some D+ donors because their D antigen is so weak that it is not detected by even the most sensitive of routine serological tests - or because despite using at least two different monoclonals the donor has an extremely unusual variant that is detected by neither. You will miss some 'D-neg' patients because they have sufficiently large numbers of D-antigen sites that they give a normal reaction with the anti-D reagents used. Follow the manufacturer's instructions for the reagent and method used and you will detect as many as you can hope to detect. And before you shoot the manufacturers because their reagent/instrument gave a 4+ reaction with a partial D known to have 10'000 D-antigen sites per red cell, and discovered because the lady made an anti-D and she is pregnant - please take a minute to think about the theory behind the serology. Maybe in years to come there will be a foolproof routine method for catching every single one……...

If this is such a rare happening my suggestion is, if it ever does happen, simply do the best you can with what you have. If you come up with some procedure then you will have to review and train with it on a regular basis and I would suggest that once per year is not enough. Bottom line, you cannot prepare for every eventuality your fertile mind can come up with. The key in the rare circumstances is to not panic or get bullied into doing something you know is not correct. You can drive yourself crazy with all the "what ifs". I am all for preparation but it must be reasonable and realistic.

An excellent post JHH1999, however, if I made the cake today, with milk that had a use by date of tomorrow, there would be grave doubt as to whether the cake would be edible today, let alone in a few days time!!!!!!!!!!!!!

Typically expiration dates are established by the manufacturer. They perform stability testing for the duration of the assigned expiration date to support it with data. Data shows the product is capable of performing up until the claimed expiration date. It may continue to function they just do not have data to support it. This should be done to support any "reagent" made that is not at least qualified in some way each day of use. Assigning an expiration date based upon the shortest dated component is not very good science. The different ingredients could be compatible with each other or could have a negative impact to on another. From a pure scientific and quality aspect one would prepare a reagent and place it on a stability schedule and test it periodically for performance. This data is then used to support the use. Any assessor should accept this science. A simple analogy I like. If you made a cake today with milk that had a use by date of tomorrow does that mean the cake is not good after a day. Of course not, since it is now in a different form and could be stored in a different way.

In my house, the cake would not make it to the next day.

I had the same thought. If you don't modify products, you don't need to have the FDA registration -- and you don't need the privilege of having them come to inspect.

It is my understanding that if you use a computer system that is validated and has been set up with logic to recognize valid typing reactions (and reject others) that you meet this requirement.

Brilliant!! Congratulations for a well deserved honor!

I just answered this question. My Score PASS  

I just answered this question. My Score PASS  

Malcolm, Thank you for your attempt at explaining this to me, you are awesome as always! I am actually shocked to hear that you have not stumbled across a B subgroup, as you have seen and done pretty much everything in the Blood Bank!!! ~KS

We use the STAT Spin Express 4 here which allows us to centrifuge our specimens for 3 minutes.

The people you mentioned are RNs and MD (Heme/Onc specialty) and do not have a Transfusion Service background although the are very good at asking questions of the Transfusion Service. They are currently working on getting AABB Certification for the Blood Management program so they have LOTS of questions. The Transfusion Service Medical Director, Supervisor and the Lead Technologist are all part of the Blood Management Committee. All policies and procedures that involve ordering, handling, and transfusion of blood/blood components are reviewed by the Transfusion Service. We also give input and review RN and MD training materials. We provide statistical information and are also involved in recommending/reviewing/testing of updates/upgrades for the HIS (Epic) which utilizes BPAM for transfusion documentation. And of course we attend all of the Blood Management meetings and they attend all of our Transfusion Service meetings so everyone stays on the same page. All in all it is a great collaboration between our 2 groups. We just had our CAP inspection in September and our inspector was very complimentary with our program.

I would think that the freshest irradiated or unirradiated unit you have on hand would be suitable for a baby in a true emergency. A full unit could be issued and tranfusionist would use what they needed and discard. This plan should be discussed with all involved before it happens to make sure everyone is OK with this. Perhaps a procedure should be written as well.

we purchase pooled cryo from the blood center. no more pooling

I would have got her RHD gene sequenced earlier in her pregnancy, so that I would have a better idea as to whether she required anti-D immunoglobulin. If she turned out to be (potentially) a Partial D, or a Weak D other than Types 1, 2 or 3, I would give a double dose of the normal dose of anti-D. Anti-D immunoglobulin is still derived from humans, which means it is a "soup" of different anti-D specificities against the 36 odd epitopes, some of which would be expressed on the lady's red cells, and some of which would not. Therefore, some of the anti-D specificities would be adsorbed onto the lady's own red cells, but others would remain in her plasma, and would be "available" to react with the red cells of her foetus's red cells, and so would give her some protection against producing her own immune anti-D.

So, a pregnant woman tests 1+ pos with anti-D. Do you give her RhIg? She has many (MANY) Rh pos cells of her own, will the RhIg simply attach to those cells. What if she tests 2+? What if she previously tested 0 (prior method for us was solid phase (or tube)) and now tests 3+, do you change her type? Do you give her RhIg now because you used to call her Rh neg even though now you call her Rh Pos? What if you didn't have a prior type on her, you'd only know her as Rh pos. What do you tell the docs when you gave her RhIg at 28 weeks when she tested 1+, but now tests 3+ and you call her Rh pos and don't recomend RhIg? We are having more and more trouble, no idea why this seems "new" to us. We currently have a pregnant woman who tested 4+ with anti-D in gel and has a history (at another facility) and anti-D and anti-E. The more we talk about this the more confused we (I) get.

It was a bit of a troll question. It seemed to me that if we can't trust the reactions we get in gel then what's the point of using it. As far as I can tell regarding the IFU's Dansket is right. I realize the importance of precision and care being taken in the blood bank, but I think a lot of times we fall victim to an overabundance of undue caution.

NO! I am a professional blood group sereologist!

Malcolm, I'm shocked!

Two other approaches that should be considered, likely employed are (1) minimizing blood draws and minimizing volume of any blood draws and (2) consideration to prophylactic use of EPO and/or intravenous iron. Both have been shown to help maintain hemoglobin/hematocrit levels in bleeding patients.

Just off the top of my head, I can't think of much more, except for the obstetricians to make sure that any preexisting anaemia is corrected by iron therapy, or vitamin B12 and folate or, in extremis, erythropoietin, so that, if there is any blood lose, the Hb and Hct are as high as possible prior to the haemorrhage (without, of course, making her polycythemic!).

Too bad you live across the pond or we might need to validate your statement by taste testing that lasagna!

No, and to be honest, and at the risk of being accused of being big-headed, I am not too bad in the kitchen. For example, when making a lasagne, I do everything from scratch, including making my own pasta and bechamel sauce.