Ensis01

Sorry to hear this. My condolences.

I have seen something similar once; if I remember correctly the BB kept track of the patient to confirm which hospital they went to, ensured the paperwork went to to our registration, who registered the patient and the BB then issued the uncrossmatched RBCs in the LIS. I do not believe there was a deviation as you have documented orders from an ER doc for uncrossmatched RBCs.

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Ok, two-Blood group policy is same principle as US second check; GET THE ABO RIGHT!! Does Australia follow the UK standards?

The US has many different organizational blood suppliers. While some organizations are national like the American Rec Cross (ARC) there are many regional and even local organizations. In my experience, each center has their own screening policy, which is determined by their hospitals requirements. A region with a high sickle cell population may send all (or most) new African American donors for molecular testing, while other regions may only screen units when specificities are needed. So, when a blood center has an aggressive screening policy, or when they are looking for specific phenotype may affect the frequencies hospitals encounter. This explains Cliff’s and my experience described above. Also, the local donor population, and/or if (and when) the blood center imports units from a different region may impact the antigen frequencies hospitals encounter . As described by other posters above, I use the antigen frequencies to primarily determine the order in which to screen antigens and to manage expectations. For example, when I need to screen for R2R2 K- units there is an approximate expectation of 2%. I would therefore screen batches of 100 units; on one occasion I found zero units, on another 9 units with the norm being between 1 and 3 units. I am jealous screening for R2R2 K- units (or any Rh combo) would not be needed in the UK!!

What is the two-Blood group policy?

I learnt that when screening to take units distributed evenly throughout our inventory to prevent the situation David found himself in, after I screened the first 15 units on the self (shortest dates) for E, which were all positive! The units after were conformed to the expected frequency. This situation occurs because reference labs will routinely batch screen for single antigen or basic combination requests from the blood center's general inventory to prevent or at least minimize use of the reference lab's rarer units.

ABO mixed field must be explained; find out patient transfusion history. If it is not clear what their blood type is, or if the mixed field cannot be explained (patient intubated, confused etc.) document and give type O. Interpretation of mixed field in gel is easy, harder in tube but I would expect it to be there. I would therefore suggest checking very carefully for mixed field by tube (this may be an occasion to use a microscope to confirm mixed field if needed). Sounds like this is a good sample to use for mixed field training in your lab.

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.

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.

I assume that as there are no decimal points involved there is little, if any, variability on day to day readings. Remember the purpose of daily checking the scale is to ensure it is fit for YOUR purpose at the max acceptable ranges in variability, which is why information is harder to find, each lab has to determine what is appropriate for them. Therefore if your inspectors have no problem with the range why would you. An additional advantage of the wide range is that you will/may see a drift in readings if the scale starts to malfunction and so have time to call someone in to fix it before you can no longer use it. I personally see no reason to make things harder without good reason or just because you can.

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There is a difference, I believe, between not being able to rule out an antibody in the context that it may be there, the answer no you state above, and not being able to rule out due to the method limitations (DTT). The DTT method limitations result in K neg units being given but once the DARA effects wears off a different, more appropriate (and better) method is used so anti-K can be ruled out and the K neg requirement dropped.

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.

If the DAT is positive I would not do weak D testing unless I could obtain a negative DAT. The primary methods I have used to do this are: EGA and CPD. I have however used 56’C heat elation for cord and neonate samples with some success, it is however time consuming.

Yes!

It is used to provide a negative control for the forward grouping, but is therefore only needed for AB pos patients. It is usually/often easier to require the control every time so it is not forgotten when the occasional AB pos does occur. The control's use in weak D testing is useful when the patient has a positive DAT.

I am a little confused; as the process to manufacture PR platelets has the same effect as irradiation what do you want to warn your techs of?

My experience is that the BB reports out the antibody identification. Never the reactivity! If a titer is ordered the only thing reported is the titer or “too weak to titer”. As the rise in titer is the most relevant result, consistency in method and technique is very important, both within your hospital system and the reference lab you use. Physicians are interested in your results not the process. Keep that simple. If they have questions your Medical Director can enlighten them.

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Agreed to all the above; as you say you have implemented a policy that prioritizes clinical benefit over inventory control and waste reduction, which the hospital (physicians, Med Techs and bean counters) follow. My experience, however, is disciplinary action taken over product wastage. So unless a hospital implements a policy similar to the one you outline, which the Med Techs can follow, giving only ABO specific platelets will be problematic.

Hi Neil, I have been following your RBC and platelet transfusion observations, and your resulting evolution of policies with interest and I agree with ABO matching platelets (also my observations). I guess however I am one of these that see too many problems for implementation, even gradual. Yes the Med Techs select the platelet, but mostly it has to be the shortest date first to minimize waste (a major concern/factor every where I have worked). A policy to only give ABO identical to a patient (one, all, or a percentage) will result in occasions where the ABO matched platelet can not be obtained locally (and may not be obtainable at all). While you mentioned both these issues and suggested solutions my experience leads me to believe it an unsurmountable task for many hospitals unless there is agreement among the physicians and/or the transfusion Medical Director can override orders (and not just advise). I can not see that happening in most institutions especially larger ones.

It makes sense to have a K neg policy while the patient is on anti-CD38 therapy, i.e. K neg units are given because DTT meant Kell antibodies could not be ruled out. Once anti-CD38 therapy is finished and if the patient never had anti-K and you can rule it out I see no reason to keep giving K neg units.

My deepest condolences for your loss.

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