Kandahlawi

We remove a segment at issue with a unit number sticker.  The nurse disposes of the bag after transfusion.  We store the segments with the daily specimens and dispose of them when the samples are disposed.  

V1  x C1 = V2  x C2  where V1 is volume of initial unit in mL, C1 = hematocrit (%) of initial unit, C2 = desired hematocrit (%), and V2 = final volume in mL
V1 - V2 =  volume of plasma to remove in mL
1.06 g/mL is approximate specific gravity of whole blood.  You will need to subtract the tare weight of empty collection bag and convert weight to volume using specific gravity.

It is anti-c. In my country, hospital blood bank still do the blood procurement, not by agency like Red Cross etc, so getting the whole blood is not a problem. We usually standby few pints of whole blood in our inventory.

you will need to know the hct of your unit.  Example:
WB of 500mL w a 45% hct =  225 ml or rbcs and 275 ml of plasma.
remove 50 mL of plasma giving you  225 mL rbc and 225 mL of plasma and a hct of 50%.
 

From the point-of-view of blood transfusion, you would give ABO compatible, Rh and K-matched units, as you would for any other case of a transfusion-dependent patient, and you give these units as often as the physician requests (but with the suggestion that a blood warmer may be an idea - but the use of same is still the decision of the physician).
As far as treatment is concerned, that is down to the physician, but usually involves steroids to damp down antibody production and, in extreme cases, possibly splenectomy, BUT, the treatment is not really the concern of either those working in the laboratory or the nurse on the ward: the treatment is purely down to the physician (we may give suggestions, as nurses or laboratory workers, but they must always remain as suggestions, as the treatment per se is not down to us).

I totally agree with Scott's answer, but will try to include some details as to why.
(1) I would think that the "cold reacting" antibody is an auto-antibody, as you say that the red cells of the patient's sample require to be washed in warmed saline to obtain reliable results for ABO and Rh, but, like Scott, I would say that the DAT and/or auto result would be required to be absolutely certain.
(2)  According to Immune Hemolytic Anemias.  Lawrie Petz and George Garratty.  2nd Edition, 2004, Churchill Livingstone. which is regarded as the authority on the subject suggests that the only test required to determine whether or not a "cold" auto-antibody is its thermal amplitude.  They say that, if the antibody is reactive at strictly 30oC or above, then it is clinically significant.
Autoadsorption will not aid you, as you already know that the antibody is not reactive at 37oC, and so you can cross-match safely.
Discovering the specificity of the antibody will not aid you as, if the specificity does happen to be auto-anti-I (as Scott correctly says, this is the most likely specificity), you would not be transfusing the patient with either cord red cells or adult ii red cells.  If it is an auto-anti-H, you would not be transfusing the patient with Oh red cells.  If the specificity is auto-a  It is true that nti-i, there is no such blood as i Negative, and so on and so forth.
Titration of the autoantibody is of no use.  It is true to say that most clinically significant "cold" autoantibodies are high titre (some very high titre), but this is not a universal finding.  A clinically significant auto-anti-I, with a particularly low titre was described by Win N, Needs M, Rahman S, Gold P, Ward S.  An unusual case of an acute haemolytic transfusion reaction caused by auto-anti-I.  Immunohematology 2011; 27 (3): 101-103.

(3) In truth, this probably doesn't matter, as, if the antibody is an allo-antibody, it is not going to be clinically significant at that temperature, and if it is an autoantibody, you are not going to get truly compatible blood anyway (see above).

Scott's comment about giving a transfusion through a blood warmer is well-made, but even then, it is likely that the transfused red cells will not last as long as would be expected.  Indeed, transfusion in cases of CHAD is often clinically ineffective, as the transfused donor cells are rapidly haemolysed by active C3b in the plasma, which binds to virgin CR1 sites on transfused red cells.  The autologous cells are relatively resistant to C3b haemolysis, as all CR1 sites are blocked by C3d/g moities.  The transfusion of donor blood causes a significant release of C5b67 complexes, which haemolyse autologous, as well as transfused cells (reactive haemolysis).

Unless a physician requests otherwise, we reconstitute to a 50-55% HCT.  The average crit of our CPDA units is ~75%, and the approximate volume is ~270mL.  By sterile welding about 100 mL of plasma, we get the desired HCT.  All packed cell units used are LR, HGB-S neg, <7 days old, and irradiated.  They would also be negative for offending antigen in cases of HDN.  If a physician requests a different HCT, we use the formula:. x= DTV X DH/ OH
x= mL packed cells
DTV= desired total volume
DH= desired % HCT
OH= original HCT
The plasma needed would= total volume desired - x
I'm sure the Technical Manual can fill-in some of the blanks.  Our LIS does all of the labeling and tracking work for us.

There is a very good reason not to use pooled cells.  Many antibodies only react with cells with a double dose of the relevant antigen.  That does not mean that these antibodies are not clinically significant.  If you mix cells together, even if, for example cell I is Jka+b- and the other Jka-b+, you are diluting out the concentration of each antigen and you will miss the antibody if it is there.  Same goes for weak antibodies in general.  Pooled cells are OK if you are only looking for the type of antibody that jumps out of the tube at you - as for example for donors, and even then, it's not ideal.  You would need a good system for detecting DPs!  I don't know anybody who tests ante-natals only using pooled cells.  If they are they should be closed down!

Do the E and S antigen typing , if it is mix field then do elution.

Hi Linyuan,
I'm afraid there is no easy way to explain all this without using a lot of jargon that make it difficult to understand, but I will do my best.
Although most people have heard of the ABO and the Rh Blood Group Systems, there are, in fact, 30 different Blood Group Systems. Within most of these systems, there are several antigens (mostly sugars or proteins that are expressed on the surface of the red cell). For example, within the ABO Blood Group System, there are three antigens (A, B and A1 - group O individuals have no ABO antigens), however, within the Rh Blood Group System there are well over 40 different antigens.
The Mi(a) antigen is found within the MNS Blood Group System (it was the 7th antigen found within this system, which also has over 40 different antigens).
Altogether, there have been something over 350 different human red cell antigens described, although, of course, no everyone expresses everyone of these antigens on their red cells.
If you lack a particular antigen, you can make antibodies against this particular antigen (alhtough you do not make antibodies against every antigen that you lack. Very often, although not always, you have to be stimulated to produce these antigens by either having been given blood that expresses an antigen that you lack, or by carrying a baby whose red cells express an antigen that you lack (expressed because the baby inherits a gene from the father that leads to the expression of this antigen). Sometimes, however, the body produces antibodies without any apparent stimulation (such as anti-A and/or anti-, although, in reality, there are stimulants within the environment.
Now, to try to answer your questions.
1) No, there is ABSOLUTELY nothing wrong with your blood, in terms of you producing the anti-Mia. Many millions of people throughout the world produce red cell antibodies, and they are as fit as a fiddle.
2) All antibodies are proteins. There are five basic types of these (IgA, IgD, IgE, IgG and IgM). All of these basic types produce lots of different specific antibodies - in your case, the specificity is anti-Mia.
The two types we are interested in, in the world of transfusion, are IgG (which are a sort of Y shape) and IgM (which are a sort of star shape). What we are looking at, in the laboratory, is the ability for these antibodies to cause clumping (the correct word is actually agglutination) of red cells that express the corresponding antigen. In your case, your anti-Mia will cause Mi(a+) red cells to clump, but not Mi(a-) red cells to clump.
IgM antibodies tend to cause this clumping of red cells without any help.
IgG antibodies, however, are smaller than IgM antibodies, and cannot "reach across" between two red cells to cause this clumping without a "bit of help". All antibodies, as I said are proteins, and all of these are a particular kind of protein called immunoglobulins. In the case of your anti-Mia, it would appear to be an IgG antibody (from the report), and one way that we can "help" the IgG antibodies to "reach across" two red cells to cause the clumping is to perform a particular test called an indirect antiglobulin test (I won't go into details - it is fairly comlpicated to explain, but is a very sensitive test), but for this test we use a particular reagent called anti-human globulin, and this is the AHG to which the report refers. So, if you require a blood transfusion, the laboratory would test (cross-match) the proposed units by this test, using AHG, to ensure that the blood is compatible with your antibody (i.e. your antibody would NOT cause the red blood cells to clump).
If your antibody did cause the red cells to clump, and you were transfused these red cells (don't worry - this blood would NOT be given to you - that is the point of the test), then your antibody could destroy these transfused red cells, and you could become very ill indeed (I STRESS AGAIN, the point of testing the blood to be transfused to you is so that this does not happen).
Haemolytic disease of the newborn happens when you have an IgG antibody of some specificity (in your case anti-Mia) and the foetus's red cells express the corresponding antigen (in your case Mia). The antibody can cross the placenta (IgM antibodies do not) and can destroy the foetuses red cells (haemolyse them). This used to be a real problem, but nowadays, as long as the pregnancy is well-monitored and, if considered necessary for the baby's health and wellbeing, there are such interventions as early delivery or intrauterine transfusions, then the baby will be born with no problems. I must stress, however, that many women have produced red cell antibodies, of many different specificities, and have had babies that are totally unaffected, despite the fact that they express the corresponding red cell antigen on their red cells - so don't worry!
I hope this explanation helps to some degree, but, if not, say so and I, or one of the many really nice people on this site, will try to explain it in a different way.

Well, there are two possibilities that are comparatively common.
 
The first is that the patient has a positive DAT for no particular reason, as do a certain number of healthy donors, in whose circulation red cells exist normally, with no shortening of the normal life span.
 
The other is that the dialysis machine has been cleaned/sterilised by the use of formaldehyde, where they can make anti-Nf, but I doubt this one, as the effect has been known about now for about 44 years, and the antibody is not normally an auto-antibody (so you would not expect a positive DAT) and it is usually not active above about 20oC, but it remains a possibility.
 
I'm certain that others will have better answers to your query.

EXCEPT - for cord bloods - they ALWAYS have to be washed at least 3 times!  I was just doing one and noticed that we forgot to mention them as the exception to the "rules" being discussed here. 
For adults - I do not wash - just make a 3% suspension in PBS from 1 drop of packed cells.  I always do tell my students that if they use too many drops of packed cells, they should wash 1 time at least.
For cord bloods, I make a 3% suspension and then drip that out to the test tubes (1 drop each) and then let the cell washer wash the those tubes 4 times.  Very easy.  (But it always requires telling the students that they must not wash the 3% suspension directly in the cell washer!!!)
 

I say change your SOP to match your practice, as long as it has been validated, passes daily QC and doesn't contradict manufacturers requirements.  I don't know of any transfusion services that wash the cell suspensions routinely anymore.

The package insert for the reagents we use says wash a minimum of 1 time, so that's what we do with patients - 1 wash. If there is a discrepancy that isn't easily resolved we would wash the specimen 3 times - haven't had to do that in a loooong time.

Excellent point David.  Actually, we do wash the red cells in PBS pre-warmed to 37oC several times over, if there is a cold-auto-antibody present that is interfering with the results.

I only wash if I get a discrepancy I cannot resolve easily

As Malcolm points out, washing is not really important for ABO grouping in the modern era of tube testing. The reagents are formulated to tolerate a degree of neutralization. I assume this is true also for the reagents used in gel cards. Washing is important when using the cells in any test using antiglobulin reagents (as LIMPER55 notes).
Perhaps more of a concern is that your in-house procedures should not contradict the reagent manufacturers' instructions. One could even argue that an SOP is not really required if you follow the package insert - that's your SOP!
Whichever approach you take, you should definitely be following your SOP. I can see and hear the regulatory folks cringing in their seats as they read your post.

The wash step used to be vital in the days when we used human-derived polyclonal ABO grouping reagents, as there were occasions recorded in the literature whereby the ABO soluble substance in some individual's serum/plasma was in sufficient amounts to adsorb the anti-A or anti-B, and thus cause either falsely weak, or even false negative reactions on some occasions, leading to ABO mismatched transfusions.
The monoclonal ABO grouping reagents used now are very different, being much more avid and much more specific to the Type 2 ABO structures expressed on the red cells, and so the washing step is no longer required.

Thanks for the responses. I read in one article, the incidence of DCT positive among donor is only around 1 in 1000 to 14,000 depend on the specificity of the methods used..i think its about time for my country to omit AHG crossmatch in the procedure..the other argument is that the reagent/screening panel cells is of caucasian origin, so we might missed out some low frequency antigen that are prevalence in our population but not in among caucasian..but again, form our experience, such case is extremely rare. Usually if antibody screening is negative, the AHG crossmatch will be mostly compatible, except in very small percentages will give AHG crossmatch incompatible (and almost all of it are due to DCT positive donor).. 

Thanks for the responses. I read in one article, the incidence of DCT positive among donor is only around 1 in 1000 to 14,000 depend on the specificity of the methods used..i think its about time for my country to omit AHG crossmatch in the procedure..the other argument is that the reagent/screening panel cells is of caucasian origin, so we might missed out some low frequency antigen that are prevalence in our population but not in among caucasian..but again, form our experience, such case is extremely rare. Usually if antibody screening is negative, the AHG crossmatch will be mostly compatible, except in very small percentages will give AHG crossmatch incompatible (and almost all of it are due to DCT positive donor).. 

I see from where you are coming, but, when we used to test donors for DAT in the UK, it was done on the satellite tubes, where the blood from the arm was allowed to flow straight into EDTA tubes, and only a small percentage gave a positive DAT.

Personally, I would not worry too much about a donor who has a positive DAT.
We know that a certain percentage of fit, healthy individuals have a positive DAT for no apparent reason, but the fact that they are fit and healthy, and have a high enough haemoglobin and haematocrit to be able to donate blood, and not keel over themselves, means that their red blood cells are almost certainly surviving normally in their own circulation (or, at the very least, the red blood cells are surviving long enough not to compromise the donors health), and they will almost certainly survive long enough in the recipient's circulation to be efficacious, even if they do not survive quite as long as would be expected.  Such red blood cells are most unlikely to be the cause of some form of haemolytic crisis, just because they are DAT positive.
In fact, the NHSBT no longer routinely test their donors for a positive or negative DAT, and we have seen no incidents as a result.

Hi, there are 2 case scenario 
1. In my country, we still do AHG crossmatch in all requested blood even though the antibody screening is negative/negative history of antibodies. Just wonder, if you do IS / electronic crossmatch only, there is risk that you might missed out DCT+ donor that only can be detected by AHG crossmatch. 
2. We provide 4 unit of O RhD+ Pack red cells to be keep at Emergency Department to be used in life threatening bleeding. We will do retrospective crossmatch (AHG phase) once they use the blood using the segment from used blood bags and patients pretransfusion sample. Therefore, we routinely check DCT to each unit before issued, to ensure there is no problem with the AHG crossmatch later on.
What is your comment? Thanks

Yeah, I've done plenty of KB stains at my old hospital ( I don't miss them )
I've been here for a year and so far have not had one patient need one.
I just wonder if that will suffice to give one dose of RhIg to an Rh Neg Weak D pos mother of an Rh Pos baby.  Or if more testing is required.
I guess we are getting by with our procedure of them not being a candidate but I don't like that.
 
I still don't understand why there is so much gray area in blood banking. I feel like there should be way to do it and that is the way to do it. 

No David.  Sadly, it was in the UK that the term "Du" was first coined (the "u" bit standing for unagglutinable) by the above mentioned Fred Stratton.  It was a very interesting paper, as was that by Race and Sanger.
 
We do not give anti-D immunoglobulin for Weak D types 1, 2 and 3, but do for all other Weak D types and, of course, for ALL Partial D types.