Ensis01

Does acquiring more good blood banking staff count?

Does acquiring more good blood banking staff count?

Have you considered that your patient could be a particularly low-grade weak D, a partial D of some kind (such as an RoHar), which would explain the anti-D in the eluate as a result of the RhoGam, or that what you are detecting in the eluate is not an anti-D, but is an anti-LW?
I also assume that the last wash is totally negative?  Sorry to ask this.

I just replaced mine last month. I used to use deionized water on the old one until I read this (taken directly from the Helmer manual):

Over my many years I have come to realize that inertia is the most powerful, driving force in the universe and the most difficult to over come!!!

Sickle trait cells do not sickle under physiologic conditions compatible with life.  Purely a theoretical construct.  Oxygen transport is also normal under physiologic conditions compatible with life. The evidence that sickle trait cells present any risks to any patient through transfusion is exactly zero.  Patients with sickle trait rarely, if ever, have any problems attributable to sickle trait. The epidemiologic evidence is likewise weak, if not zero.

Are you using tap water? You could switch to distilled water.
 

There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong.  See below for the reasoning and published data.  We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data.
BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1
Letters
Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data.
In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5
We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients,
such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply.
Competing interests: None declared.
1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250
2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995
3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A.
4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246
5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
LETTERS

I agree. You do the best you can with what you have. Unless your blood supplier or a large neighbor who can transfer product is close by, you are not going to be able to ship in product in time. It is cost prohibitive for us to stock product routinely for an event that occurs very infrequently (and your blood supplier may not be very enthused about the constant rotation of product). 
We are 150+ beds, have a NICU, and are one of the 'large' hospitals in our rural area, but still transfer our critical neonates/kids to Children's 150 miles away. We only transfuse babies and small children 1 to 3 times over an average year. Our facility sees quite a few Onc patients, so I do stock a small inventory of irradiated products including 2 O neg Irrad on top of our normal O neg stock (if we can get O neg - fun times!). If we have time to crossmatch, we provide the freshest type specific unit (if we know mom's type) on the shelf, irradiated if requested and we have it in stock. If not, we provide the freshest O neg unit on the shelf, irradiated if requested and available. Children's gives LR as CMV neg equivalent, so that's the policy we follow. I don't stock syringes because we would outdate almost all of them and our software is not set up to split/label units. (It would be very rare for us to even have the possibility of pulling blood off that unit a second time, so not worth setting up.) We hand over the entire unit and the pediatrician/nurses pull what they need for transfusion in the 4 hours after issue.

@rmilford, have you considered the DCLS program at UTMB? Since you are considering the SBB, which I think is worth the knowledge alone, you may find that the DCLS program will do the same and more, giving you a terminal degree. I anticipate the role of DCLS will become important in healthcare in the near future. It also opens up more possibilities outside traditional lab roles, including teaching higher education.
Just another thought.

The BB supervisor sent a certified packet to the physician on record. We included a letter documenting the transfusion, a copy of the current FDA requirements for notification, and a form for them to complete and return by a certain date with the notification information. The Medical Director’s name and phone number were in the letter as the contact person for the physician. The Medical Director was copied on this info in case he was called.  If the completed form were not returned, the Medical Director called the physician.  Every phone call, etc, was documented.   There were problems, as mentioned above. We had hospitalists who only treated the patients in the hospital who might not work there anymore or did not feel responsible for follow-up.  What if the patient went to rehab and never went home?  If we could not reach an end point, we sent to risk management for resolution. 

Precisely! Our current conundrum is a snarky Ortho attending who is insinuating that our blood supplier and my blood bank gave the patient "contaminated blood" and he shouldn't have to be the person to notify the patient. Snarkiest of the snark, and its clear there is little understanding of the risks of transfusion. 
My medical director wants to involve our Patient Safety and Quality folks or Risk/Legal, since this is an FDA requirement, and I think we'll have to take that route, if for nothing more than educating the physicians. 

This is one of the biggest frustrations of my job, exactly as you have described it. Our Medical Director does not want to direct contact patients/family members. Some treating physicians do not want to take responsibility for this. I would meet with your director of quality and facility chief medical officer and get them involved by first helping them understand the FDA requirements. They can help educate treating physicians on their responsibility when they order transfusions. A lot of these physicians do not understand that this is a real risk. Perhaps that will tighten up some of their maverick blood ordering practices. 
I recently had one where the donor tested repeated positive for HIV. The patient is now deceased but did spend time with his family between the time of transfusion and his expiration. 2 years later, we are battling how to contact his spouse and mother, both of whom cared for him in the interim. We do not even know what primary care physician to contact in this case. If we did, I guarantee they will not want to cause that kind of alarm in the surviving family, possibly risking a law suit.

Getting your SBB is great knowledge to have, and I agree with Cliff that it will open more doors for you to do other things. Having worked in large busy trauma center BB's for 17 years now, I can tell you that my SBB knowledge rarely comes into play in a hospital BB, unless you have ALL the things (complex antibodies, washing/irradiating product, neonatal population, ref lab for system hospitals etc). If you have goals of Ref Lab or a private company, many of them require an SBB. You can also get in with a teaching program with an SBB easier than without. I've heard many hospital labs would like to have their admin directors be blood bankers with an SBB, as it brings a quality eye that other candidates don't have, but it seems rare to find those people because so few of us want to do that job!  As far as helping you run your blood bank, it likely won't be that beneficial, as most of the curriculum is a deep dive into antibody qualities and rare things, but there is some info on supervisory duties and such. 
I graduated from LifeShare's SBB online program in 2019, after having worked in the BB for 10+ years. I personally liked the online program, as I already was the supervisor of the BB at the time, had two small kids and was not able to move across country to attend a program in person. LifeShare and UTMB share their curriculum, and an SBB from LifeShare is eligible to go on to the Masters in Trans. Med from UTMB should you wish to do that. Katrina Billingsley is the director of the program at LifeShare, and she is fabulous; would highly recommend her program. 

Here the Medical Director or designee is the one responsible for contacting the patient's physician. If the patient's physician refuses to contact the patient, our Medical Director or designee will end up having to do it. 

We do not routinely transfuse neonates (have not done one here in 30 or so years).  We would give the freshest O= we have; irradiated if we have one.  We are 3 hrs from our blood supplier.  Chances are the infant will be transfused before we could receive appropriate products. 

If the unit if leukoreduced, as all red cell transfusions should be, there is no need for CMV negative in my view.  

I expect that you will see an increase in your knowledge base.  No matter how busy a BB you work in, you may not get the minutiae you need to pass the SBB.
Good luck. 

I wouldn't think you need to create a new policy, you should already have a policy regarding situations requiring path approval or regarding a deviation from your SOP. Agree with what was mentioned previously in that a conversation must happen with your medical director and ordering MD. The blood shortage is worldwide with the donor pool going up and down so this shouldn't come as a surprise to the MD.  We also switch male patients (not that often) but the MD's understand the situation. We note it in the patient files the date and how many Rh pos units were transfused just for tracking and in case an anti-D is made. 

This is a clinical call that we make between the senior medical technical staff present and the attending physician.  We routinely switch male patients, and older females who are Rh negative to Rh positive red cells when transfusion rate is significant and supply constrained. No policy.  Just a clinical decision, which we communicate to the treating team.  Typically a liver transplant that has gone badly, an exsanguinating trauma patient and similar situations.

Phew, I am certain I do not deserve those kind words, and nor am I sure that I can live up to them, but I will do my best to explain Kea.
The first thing to say is that not everyone who is K Negative, as your father must be, otherwise he would be unable to make anti-K (which is what they mean by saying he has made anti-Kell - VERY bad nomenclature on their behalf!).  Except in certain, rare, pathological conditions, one does not produce an antibody against an antigen expressed on one's own red cells.

I suppose really, I should start by explaining some terms.  An antigen (in this case, I am talking about something expressed on the red cells - they can also be expressed on white cells, platelets and other tissues within the body - but that will complicate things more than is required, so I will stick to red cells) is a structure on the surface of the red cell (usually either a protein or sugar) that, if these red cells are transfused to another individual who does not express the same antigen on his or her red cells, can stimulate the recipient's immune system to produce a specific antibody directed against this antigen.  This antibody can lead to the destruction of the transfused red cells, should such antigen positive red cells be transfused to the same individual a second or subsequent time; so, in this case, if K Positive red cells are transfused to a K Negative individual, the recipient may produce an anti-K as a result, and if K Positive blood is transfused to this individual a second time (after a few weeks or months), those K Positive red cells may be destroyed in what is called a haemolytic transfusion reaction (please excuse my English spelling!).  Another way in which such an antibody may be produced is if a woman is, for example, K Negative, and her baby is K Positive (the K gene would have to be inherited from the biological father for the baby/foetus to express the antigen on its red cells).  Some antibodies are produced "naturally", without stimulation with red cells.

Two things are important to say here.
Firstly, an antibody is NOT produced by everyone when they are transfused with red cells that do express an antigen that the recipient does not express (or the pregnant woman does not possess -despite the fact that in almost all pregnancies there is a small bleed from the foetus into the maternal blood system).; the production of an antibody is by no means automatic.
Secondly, the transfusion of antigen positive blood to someone who has made such an antibody does NOT necessarily mean that they will have a haemolytic transfusion reaction (certainly not one that is clinically significant). 

So, getting back to your family, your father MUST be (or have been) K Negative, and MUST have been transfused with K Positive blood at some point during his life (he, fairly obviously, could not have been pregnant with a K Positive foetus - and, if he was, I want to be his manager!!!!!!!!!!!).
Now, for an antigen to be expressed on an individual's red cells, they have to have inherited a gene, either from their mother or their father (or both) that encodes for that particular antigen (genes are inherited, but antigens cannot be inherited - they are the result of inherited genes).
Antibodies, on the other hand, which are found (normally) in the plasma (the "watery" part of the blood) once they have been stimulated CANNOT be as a result of inheritance (except very loosely, in that some, very rare individuals, never seem to produce antibodies, however many times their immune system is "challenged" by a "foreign antigen").

This means that, unless your elder sister is, as is likely, K Negative and then received either a K Positive transfusion, or was pregnant with a K Positive foetus, she is unlikely to have produced an anti-K.  Similarly, if, as is likely, your brother is K Negative, he is most unlikely to have anti-K in his plasma, unless, at some point during his life, he was transfused with K Positive blood.  The fact that antibodies are NOT inherited, it is highly UNLIKELY that your nieces and nephews will have anti-K in their circulation.
The McLeod phenotype is very, very unlikely, as is the McLeod Syndrome.  They can both be inherited but would result in antibodies of different specificities than anti-K but may well also result in certain other pathological symptoms, so I really wouldn't worry about that.

Sorry, I have gone on a bit, and I hope this helps, but will attempt to attach a PowerPoint lecture that may explain things further, should you be so obsessed as to read it!
If this is not what you wanted, I would suggest you ask another member of this group, named "Danny", who knows more about the subject than I ever will.
In Depth Lecture on the Kell and Kx Blood Group Systems.pptx

We also would not consider discarding these products. We transfuse about 25,000 rbc's a years, with a guess of 9% pos, we'd need to discard 3,600 units of blood, and eliminate them as donors. I can't imagine that.
We do have certain groups of patients we give K neg to even if they don't have the antibody, but we still use the units for other patients.

We don't do special antigen typing of our units unless we do it specifically for a patient who has the corresponding antibody. Do they do this because the Kell antigen is very antigenic? It would seem to me, that it would be costly to type units for Kell to avoid using Kell positive units, unless of course the units are for a patient with anti-Kell.

The timing for fresh samples is somewhat different in the UK than in, for example, the USA.  The timings, and the reasons for these timings, are set out in paragraph 3.7 of the BCSH Guideline "Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories" (written by Claire Milkins, Jenny Berryman, Carol Cantwell, Chris Elliott, Richard Haggas, Joan Jones, Megan Rowley, Mark Williams and Nay Win, for, and on behalf of the BCSH, and published in Transfusion Medicine 2013; 23: 3-35.  doi: 10.1111/j.1365-3148.2012.01199.x), with the Key Recommendation of this paragraph being, "Serological studies should be performed using blood collected no more than 3 days in advance of the actual transfusion when the patient has been transfused or pregnant within the preceding 3 months."
As I understand it, this timing was based on the work originally carried out by Professor Patrick Mollison many years ago, who found that a new specificity of an alloantibody, or a nascent antibody that has become undetectable by normal serological techniques, can appear (or reappear) in the plasma of an individual within three days, after stimulation.  The problem is that not all patients know whether or not, or when, they have been transfused, or may deny it for religious reasons (I once cross-matched for a patient who had been a life-long Jehovah's Witness, who had an anti-Fya in his plasma that had a titre well in excess of 128).
I hope that helps.

I just read through the regulations again to update our lookback policy and I did not find any such date.