Ensis01

I like this as a rise in temperature can be due to the temperatures being taken by different methods or locations (oral, rectal or armpit). SMILLER's phrase ensures this is incorporated into the evaluation process.

Firstly kudos for taking the initiative and getting outside opinions to the changes you are experiencing and are uncomfortable with. The above comments (from way more experienced blood bankers than I) indicate your new supervisor is not wrong but needs to clarify the new process in context for you all. I suggest following AMcCord's advice and pulling some past work-ups (or invent them). Include patients with a new and previous single antibody, also patients with new and previous multiple antibodies. Then get the supervisor to walk through how he would resolve them and explain how each work-up would change with a negative and positive DAT. Running a DAT with each work-up is fine as long as it is clearly laid out what you are to do with the results and why. Once you have "proved" an antibody according to policy, running only negative cells for that antigen is normal practice because it is efficient (especially for the anti-e mentioned above). This is however assuming you have manual gel, as Dansket said only full panels can be run if automated. Hope this helps.

My understanding is that when collecting the blood from the donor; several tubes are collected and sent off for testing at a BIG lab, this includes the ABO/Rh (as well as bacteria, diseases etc.). The donor center would only test ABO/Rh if the BIG lab determined a serological discrepancy or if the ABO/RH was a historical mismatch for the donor (these would be resolved by a tube not segment). The only time a donor center would need to confirm an ABO/Rh by a serological test from an attached segment AFTER labeling is if the donor center's reference lab was working as a transfusion service for a hospital.

WOW; a real can of worms! Just for fun and off the top of my head here is my opinion. PPE is by definition to protect the techs. The lab lay out should allow a transition location to don lab coat. When entering lab proper; add gloves and safety glasses (ask anyone who has had their head in the eyewash for 15min). Gloves should be changed when visibly soiled and periodically as they loose their impermeability over time (I remember reading either vinyl or latex in ~20min). Wash hands when changing gloves. Put face shields in key locations. Small reagent/blood smudges on paperwork are taped over, if larger spill occurs put in plastic folder and photocopy. If this is followed the tech is protected and contamination throughout the lab minimized/contained. Gloves are prohibited but lab coats required in labeled "Clean" areas of the lab that are used for issuing blood products and manager/Sr. tech paperwork. Blood products worked on in the lab are handled with gloves but products are issued without gloves and placed in Ziploc bags so that if dropped leaks are contained. The RBC will be taken out of the bag and hung by an RN wearing gloves. Yes I know that it is purely semantically that if working on a RBC I wear gloves but when issuing the same unit I do not. It does however provide a clear distinction as far as writing and interpreting policy. The last thought is that whatever you decide is your policy; it must be practical and enforceable or will not be followed by the techs and therefore only an academic exercise.

Congratulations Malcolm!!!!

Am I missing something? I always understood that the use of transfer packs or syringes was to minimize waste, i.e. several transfusions from one RBC. This seems like a lot of extra work in the BB just to make life easier for the nurses. On a practical note it may be easier for you to determine X as a max weight for an RBC unit. See if the ped docs are OK with your average unit and use that weight. So an RBC less than X can be chosen, it's weight entered in LISS, then XM and issue as normal.

As I was talking about hrB and hrS I am to blame. Bioinformatics and blood banking; a minefield of possibilities and headaches

OK playing devils advocate for fun: the anti-C and anti-e were identified as allo-antibodies, as the article reported that the patient lacked the antigens, so phenotype R2R2. If the policy was to give patient's Rh and K matched RBC, then exposure to HrB (and HrS) would have been avoided (I can not figure out the frequencies of RBC that are e neg and HrB pos and Jeff Daniels was making my head spin, again). Blood 2013; 122: 1062-1071: I like these types of paper as they empirically, and definitively show the complexity of transfusion medicine and in this case of the Rh system, which reminds me how much I have to learn. Correct me if I am wrong please, but it seems that the Bioarray assay shows genetic mutations but does not identify some antigens, for example it does not seem to separate the e antigen mosaic and identify HrB and HrS, which the newer assays can. So my question is how many cases of alloimmunization in sickle cell disease the paper describes over the 13 year period would have been avoided if our current knowledge of the Rh system was utilized? Ask the same question in 5 years time!

The way I read the article; the lab has a policy of only running the ficin panel if they cannot clearly explain the reactivity, which seems like a good idea only if the ficin panel clarifies the reactivity. The article states that this occurred frequently enough that it was cost and time effective as fewer samples were sent to their reference lab. I assume that if the ficin panel does not clarify the pattern more confusion results, as exlimey said, and they send the sample to the reference lab. So sounds a reasonable policy if the techs can interpret the results correctly. The article also used an example of identifying an anti-C and anti-e in a sickle patient; most transfusion services (several threads on this site) match Rh and K for these patients.

Rh/K for WAA and SS patients, plus neg antigens for any antibodies made. There are several papers (based on SS populations) that show matching Rh and K will effectively prevents the patient developing antibodies (with exceptions). I can not remember the papers though.

I do not know as we always phenotype using tube. You may however have issues as the IgG DAT will be more sensitive in Gel, and the MTS diluent 2 may affect the fragility of the cells (or not).

I seem to remember that the concentration of platelets in plasma is an important part of QC for the 5 day expiration, something about pH changes over time I think, which may be why platelets come as singles, doubles and triples? I would check/clarify with your blood bank/supplier. As applejw said; you are changing the environment, which may impact the functional survival of the stored platelets.

EDTA Gyycine-Acid kit. Often used in the USA instead of Gamma-Quin to dissociate IgG from red cells. It has the advantage that it is faster than Gamma-Quin but the disadvantage that it inactivates the antigens from the Kell system. DCeDCe: my advise is to follow the insert very closely i.e. to the second. If the DAT is strong you may need to do the process twice (max). Once treated the cells are often fragile and so test with little delay. If the complement DAT is also positive a higher degree of hemolysis and cell fragility occurs and so reducing the incubation time is often needed. I suggest beginning by EGA treating out of date screening cells that are K pos and k pos then test with anti-K and anti-k to see if the antigens have dissociated. Then move on to DAT positive cells with IgG only. Hope this helps.

My apologies you are correct, monoclonal reagents rule out polyagglutination in the DAT (Isset, Harmening and Daniels) and I should have said: "Therefore if the patient's Poly or anti-IgG or anti-C3b,-C3d DAT is negative; false positive results are ruled out and the saline control is not needed."

Daily QC shows that the Poly, anti-IgG, anti-C3b,-C3d, CC and CCC reagents are working correctly and negative reactions at the AHG phase show the cell washer is removing free IgG/IgM. My understanding is that the DAT negative saline control is only required when the patient has a positive poly, IgG and compliment DAT. The DAT saline control, when negative, rules out pollyagglutination (either microbial or acquired). Therefore if the patient's Poly or anti-IgG or anti-C3b,-C3d DAT is negative; pollyagglutination is ruled out and the saline control is not needed.