MOBB

How do you monitor the temperature of your units? Do you use temperature indicators or just a thermometer? If you don't use indicators on the units, do you worry about units taken out of the cooler, going out of temp and then returned to the cooler and returning to acceptable temperatures before returning to the blood bank? We've used safe-T-vues and had terrible luck of them turning red on in temp units. We used the hemo temp II's, but they're only good for 24-36 hours so not the best for trauma's. We validated BT6's, but now we're having issues with them turning blue in the refrigerator. I'm just so frustrated at the moment.

Is blood sent to the ED for traumas considered transport or storage? I thought it was storage since it might sit bedside up to 4 hours, but I'd read in another pathlabtalk thread that the FDA and AABB now said it was transport. I've been googling, but can't find any references to support it as transport. Our blood supplier said anything less than 24 hours is transport, but they haven't sent references yet either.

Our current protocol is to genotype our WAA, SS, patient's with multiple antibodies, and anyone else with difficult workups. I read that the Swiss genotyped their blood supply rather inexpensively using the Maldi-Tof. I could be wrong, but I think it only cost them $80,000-$30/donor. This was mind blowing to me since we pay significantly more than $30/genotyping and it's the HEA one that does not include all the rares and variants.

That would be awesome :)

I'll apologize in advance for the lengthy answer. I had always been taught that matching Rh and Kell were helpful in preventing alloimmunization for SS patients, but I attended a lecture by Dr. Gehrie last week on this topic and he had a very different opinion. I'm looking forward to discussing this with my medical director-it's so different from everything I've previously read. Dr. Gehrie said the 2014 NHLBI Expert Panel made a moderate recommendation based on low-quality evidence that RBC units that SS patients should include matching for C, E, and Kell antigens and that serologic antibody matching programs results were varied. He also advocated that only 30% of SS patients form alloantibodies which makes studies difficult-patients may not have made antibodies, but maybe they are part of the 70% that wouldn't make antibodies. He shared the Chou et al 15 year retrospective analysis from Children's Hospital of Philadelphia. The patients were provided D, C, E, and K matched RBCs from mainly african american donors. N=123 chronically transfused, N=59 episodically transfused. 58% of the chronically transfused and 15% of the episodically transfused were alloimmunized. 91/146 antibodies were to Rh antigens. The biggest takeaway for me was 87.6% of the patients had Rh variant alleles which help explains the alloimmunization rate. Dr. Gehrie's protocol at Johns Hopkins is to do nothing for SS patients until they form an antibody, then genotype the patient and provide matched products based on the genotyping.

Excellent suggestions. Unfortunately, our fabulous consultants won't explain how they arrived at their recommendations because it's "proprietary".

Our policy is written to allow the blood bank to order products in emergent situations to avoid potentially life threatening delays for the patient. We do not order lab tests for the patients though.

I'm still validating them. At first we would see a sliver of blue at 4-5°C, but I think we figured it out. After activation, it has to be stored at </= 3°C. If we put it on a frozen ice pack for 15 minutes, it doesn't activate at lower temps. The problem I'm having is it will start to activate at 5-5.5°C. We can temp it with an infrared gun to avoid wasting the unit, but will have to write the policy to reflect that process.

Not for lot to lot testing. You want to prove a positive on the old lot is positive with the new lot and the same for negatives. You don't have to use the QC from the old lot with the new lot-you could use a known negative and positive depending on how your policy is written.

For weak D in gel, what QC do you perform?

How do you ensure they have everything in place prior to issuing the unit? It's very very rare but we do get the occasional, "we forgot consent".

The patient takes loratadine. It doesn't look like brompheniramine or phyenyltoloxamine are ingredients and I see loratadine listed anywhere interfere with their reagents. We diluted our 3% reagent RBCs to a 0.8% suspension with Grifols diluent and the gel screen is negative.

1. For Pre-Ops, when do you get that 2nd specimen? Pre-ops get their retype the morning of surgery when they start the IV. 2. For Outpatients, when/ how do you obtain that 2nd specimen? Same process as pre-ops. When they come in for transfusion, a retype is collected if needed. 3. For Inpatients they want to transfuse, what is the protocol? We document the history was checked and a retype is needed on the original type and screen order. If the floor needs to transfuse, they have to collect the retype. We will crossmatch a unit of O neg if needed while they collect the retype. 4. Do you require it just be a different time of draw, or does it also have to be a different phlebotomist? We are a nurse draw only facility. We do not require a different collector-just a different time of draw. Retypes can only be collected in the pink 4 ml tubes and only blood bank has the tubes. We will not accept the 6 ml tubes for a retype since it was most likely drawn at the same time as the original type and screen. Blood bank places all the retype orders in EPIC and sends the needed tube to the floor, infusion center or OR. We will use a purple top and sometimes green or blue from another draw already in the lab for the retype too. This specimen will not have our unique BB number, but must match the MRN, DOB, and name and be stored appropriately and not adulterated in anyway.

I really like this idea. Do you use the History field for documentation of the history check too?

Our rehab hospital bands their patient, collect specimen and send it to our blood bank. We test and send units back to them for transfusion. We would not allow a patient to have testing at hospital A and be transfused at hospital B, but I think if your system is set up with a centralized blood blood bank, it is possible. When I lived in King County-Seattle, WA-only the blood center could do blood bank testing so we sent samples by cab and they would electronic crossmatch units in our blood vending machine or send cross matched units back by cab for us to transfuse.

We do not, but we also put temp indicators on our units to verify the cooler wasn't left open or the units dumped on the counter for a while before returning to the cooler. Purely anecdotal: years ago my hospital didn't have the digital trackers so I tried validating the coolers with checking temps every hour-they went out of range within 4-5 hours. They stayed in temp over 12 hours not opening the coolers.

Patient denies any previous transfusion and has a history of 2 surgeries at a surgery center (highly unlikely to transfuse, but not impossible). Patient does not remember the name of the surgery center. Patient is pretesting for surgery. Thursday: Sample 1 Patient type: O pos Patient Screen: 4+ for cell I and II in grifols gel Patient Panel: 4+ for cells 1-11 and auto control is negative in grifols gel. Patient was called back in to collect additional samples. Friday: Sample 2 Ref lab reports probable cold auto with DAT IgG (gel) negative and DAT C3 (tube) 2+ Ref lab said they used ortho gel with immucor RBCs and had no reactions. They did get 2+ reactions in tube with PEG and positive reactions with a papain panel in ortho gel. Monday: Back at the hospital lab, we were confused by the ref lab reports. We questioned why the auto was negative and they suggested possibly the patient did not fully develope I antigens and had some i antigens which would explain the 4+ on reagent RBCs and negative on autocontrol. It was discussed that the positive complement DAT pointed to the autoantibody and gel does not typically pick up complement well hence the negative auto, but it does not explain the 4+ reactions with the 0.8% reagent RBCs. Our pathologist recommended a blood warmer for any transfusions. When communicated to the Surgery Coordinator, she said the OR room will be 50-60°F and the patient temp will be dropped to 34°C. Would a blood warmer be helpful with already low temps? Could the cold temperatures cause a reaction in the patient without any transfusions? Out of curiousity we did additional testing on Sample 1 (day 4) Grifols Tube screen: negative at IS, 37°C with LISS, and AHG Grifols gel screen: still 4+ cell I and cell II 2 random O pos units XM in grifols gel: both compatible-I'm thinking this rules out the undeveloped I antigen theory If we didn't have the ref lab workup, I would suspect a reaction due to an additive or something in the 0.8% reagent RBCs. Tuesday: Contact the ref lab to ask if their medical director recommends a blood warmer for this patient considering the antibody ID and temperature requirements for surgery. Medical director recommends thermal amplitude studies at 30, 34, and 37°C on their sample collected on Friday. No reactivity in the sample-ref lab thinks the it auto absorbed. We can't explain why my 4 day old sample had reactivity, but their's did not. Patient did not want to come in last Friday and probably won't come back before surgery. He claimed ARC never had any issue finding him blood. I've heard ARC does not do gel testing so based on my testing, maybe their screens were negative and all crossmatches were compatible. Ref lab is confused. We're confused. I'd love any insight. I keep hoping I'm missing something obvious... Do you think it's a cold auto? If so, would you do a tube type, screen and crossmatch for surgery and skip gel altogether? Would a warmer be helpful? Thanks!

Wow. Are there published studies?

I was thinking it was something older they were referrencing, but I need something more than, "I don't think that applies anymore." Because I tried already tried that I also told them RBCs wouldn't be in range at 30 minutes and would need to be temped. To which they wanted a hard number of how long-they seemed irritated when I explained it could vary on number of RBCs to temp of the room to so many factors.

Are there any study guides you'd recommend since you didn't attend a SBB program?

How do you bill for plasma reduced or HCT adjusted RBCs? It's a very tedious process for our pediatric BB, but we're being told there is no billing code so it's billed and in turn does not get included in productivity

We are working with nursing on their blood administration policy and the FDA 30 minute rule came up. Do you require nursing to return blood if not hung within 30 minutes and not in a temp. controlled container? Our current policy is to waste any RBC returned to the BB, so we encourage them to hang and complete within 4 hours of transfusion if something happens like losing a line. Are we in violation of the 30 minute rule? I tried googling, but didn't see much current information. Oddly, Nursing also seems to be under the impression the 30 minute rule means it can be returned and reissued later. We are in the process of updating the policy and validating infrared thermometers to allow us to return products if they are within transport temp.

We used to use the J survey, but dropped it to only do the JAT survey. It was too crazy last year when J, JAT, and DAT surveys kept dropping at the same time. We will do split samples between our local network blood banks instead.

We store our reagents in a blood bank refrigerator and I keep the range 2-6°C so it meets the needs for both blood products and reagents. It's been handy when one of the refrigerators has an issue-there's no questioning if items were stored at the appropriate range. When we have needed a back up refrigertor, not all of our reagents and products fit in one fridge and we move some of the reagents to heme and take temps every 4 hours.

Lily at CAP said it was only for the FS kits and daily QC is fine for everything else. When I called back in October with my list of questions, I got the feeling she thought we over interpreting many of the items