Ensis01

I am enjoying this interesting discussion.

I am enjoying this interesting discussion.

Test a K+ or k+ DTT treated cell by your normal method, if you have a choice use the quickest method.

I don't think gel testing eluates has been a problem for us either, although in the past there have been isolated incidents where the results were questionable that we have attributed to technique and have cleared up with retraining/competency observations.
 
You know step 9, where it says to mix well and centrifuge to remove any precipitate or cellular debris, then transfer to a clean labeled tube? We do that step several times. Since we've been doing that there are very few problems with weird reactions.

The thing to keep in mind is that we do not order tests and we do not determine what is unnecessary.  You can take your concerns to your medical director or some committee but I have found over the years that unless it is something life threatening most medical directors I've worked with are unwilling to challenge another doctor's ordering practice so viewing such practices as job security is simply a coping mechanism that gets most of us through the day.  There, more philisophical drivel! 

I've always wondered how on earth people had the time and money (and slave laborer research assistants) to do this? How many other seed extracts did they have to search through before finding the dolichos, ulex, vicea etc that did something with certain red cells and not with others. And finding the best recipe for preparing it. What a colossal amount of tedious work! I have trouble just finding the second blue sock in my sock drawer. Happy Thanksgiving to all.
Phil

Also ticks the box for safety when the second type (for none type O patients) comes from a second separate sample. 

Wow, can't remember the last time I read a 4 page thread from start to finish! 
 
Txlabguy82 this is definitely one of those "s....tuff happens" occasions.   Personally I see nothing in your process that would concern me,  Actually there is a fair amount to commend you for.  As far as this possibly being a sample problem, I think not.  I've used short sample EDTA tubes far more often than I care to admit.  I guess, just to join in on the questions, could the sample have agglutinated as opposed to clotted?  Just a random thought and not real sure where it's going but it did come to mind as I was reading. 
When I was supervising blood banks and transfusion services I never got overly excited about the random one time occurrences, especially those where no real cause could be pin pointed.  The corporate Transfusion QA group hated it when I would remind them that as long as humans were involved in a process there would be the occasional human error.  Now, whether or not this particular case was human error will probably never be determined.  Bottom line; the patient received her dose of RhIG because the process discovered a problem.  Why the problem occurred will, most likely never be truly determined so don't let this eat at you over much.  My recommendation, find employment as a dedicated bloodbanker and enjoy the rest of you career. 

If there were 2 populations of cells, and if the fetal cells were ABO incompatible with the maternal sample however D positive, the fetal cells could have been hemolyzed in vitro by the time the sample was retested 10 hours later.  Since the fetal cells were no longer intact, the repeat testing would have been on exclusively maternal cells and tested as D-negative. 
 
I realize your initial forward type did not detect/report the presence of mixed field agglutination.  With monoclonal ABO antibodies and using tube testing, it is often very difficult to detect mixed field reactions with small populations of other cells.  It seems the monoclonal ABO antibodies are so avid, the agglutinates seem to "trap" the other population of cells in the agglutinate rather than remaining free to be resuspended. This was demonstrated years ago when the AABB offered "damp" workshops where samples were provided for testing, registrants reported their results and results were tallied and presented to attendees.  During the time when the older polyclonal ABO reagents were still in use and the monoclonal reagents were just being introduced, the results indicated a significant difference in the detection of mixed field agglutination in the forward ABO testing between the groups using polyclonal reagents (MF detected) vs. monoclonal reagents (MF not detected).

The baby has not been proved to be D Negative, as the DAT is positive.  Until the cause of the DAT is fully understood (you are correct in saying that it could be as a result of an ABO incompatibility, or an antibody directed against a low prevalence antigen, but it could equally be anti-D, or a combination of any of these causes), or that the baby is expressing a weak or Partial D, which cannot be proved or disproved while the DAT remains positive.  Under such circumstances, the mother should be offered anti-D immunoglobulin (as a belt and braces exercise), and if the offer of anti-D immunoglobulin is accepted by the mother, you are duty bound to make certain that the standard dose is sufficient.  If this is not sufficient, a calculation should be performed to ensure that a sufficient dose is given.
THERE IS NO ROOM OR EXCUSE FOR GUESSING IN ANY AREA OF BLOOD TRANSFUSION.

Clinical management of the patient can be tricky - and sometimes no matter what's done, there's not a good outcome.
We advise following liver function and renal functions.  Much depends on if the potential Ag/Ab reaction causes intravascular hemolysis.  We'd particularly watch LDH and creat.  We may recommend hydration/Lasix to keep those kidneys flushed.  If hemolysis is severe, and LDH is high, we may recommend a red cell exchange.  Which may or may not help.  By the time you're seeing brisk hemolysis, most of the donor cells have been destroyed and there's little to exchange.  Plasma exchange is also an option.
But many times in an ABO mismatch, these things can happen quickly.  The sooner the BB med director knows, the sooner he/she can help guide clinical management.

I know I'm a little late responding to this thread, but I didn't see the answer I would've provided, so I thought it worth mentioning.  When we would EGA treat a neonate red cell to rule out weak D we would run a drop of EGA treated red cell with an in house 6% albumin as our negative control.  The control served the purpose of verifying positive reactions were truly due to the presence of the antigen and not the result of an incompletely removed maternal IgG.  We did do an extensive validation prior to using the EGA kit however, verifying which antigens were denatured, so we had complete confidence the D antigen was left intact. (Immucor was correct by the way, and the validation was completely unnecessary.)

I love this thread - the blood bank geek in me is enjoying this very much!!!

We will rule out C and E in the presence of anti-D with a single C+c+ or E+e+ cell.  K may be also ruled out with a single K+k+ cell.

Heather - don't panic! You will have bright minds in your own centres - it's just a case of identifying them.
I don't envy your job - your biggest challenge will be stamping out ingrained habits that are terrible practice. Every lab has that one tech who just does it their own way despite the SOPs. They're easy enough to identify as they are the one that noone wants to take over from, and if they have to they will start again rather than taking over and continuing

Great post and exactly my point. Blood bank needs to ensure that our requirements are met but it's a nursing documentation/workflow issue.

A little late on this subject but I thought I would chime in anyway.  We suffered the same problem as you described a few years and 2 employers ago.  When trying to determine what to do about it we discovered that the nurses were being "required" to document the same information in multiple places.  This made no sense so I worked with a team from the nursing department and we came up with a system that only required the documentation in a single place and did away with the other locations.  An example is that they were being required to document vitals both in the patient's chart and on the transfusion record.  Obviously they were much more in tuned to documenting this info on the chart so we removed it from the transfusion record.  Any inspector who wanted to see the info was shown the chart.  Over the years I have discovered that simplifying a process usually enhanced it.  

If the information is required, then it is required.
If the nurses can't be bothered to fill it in, go down the disciplinary route.
If the information is NOT required, then ditch that bit of the form.

Dr. Pepper, it's no wonder you're a blood banker!  Search for the answer and never give up until you've found it.  Bravo!

That's what I was getting at.....but then, I got curious, and looked it up to see if it was actually true about water draining one way or the other. It turns out that in a perfect, static state of affairs, Coriolus forces can indeed cause the hemispheric effect, BUT in the real world those forces are vastly weaker than other influences at play and are overcome by variations in the shape and structure of drains and tubs, motion of the water in a basin caused by use or a slightly off center (which they all are) faucet filling it up, and so on. Hence it joins a long list of charming but untrue urban legends. There's an equatorial nation where, for a modest fee, you can see a toilet on the north side of the line flush in one direction and one on the south side flush the other. They're rigged.

We hired one last week for 3rd shift.

Same reason I do not store my Guinness over my toilet...
 
Scott

On our previous computer system we had the option to write in the lot number and expiration date of the antisera when we were antigen typing. But it was really cumbersome and time consuming. It was also hard to tell if someone had done QC on a particular antisera for the day and if we didn't know we would have to repeat it. So, we went back to writing on paper and it seemed to work better for us. We can flip open the book and tell at a glance if we need to do QC on JkB antisera no matter what shift you are working. The computer is a great aid but not always the best answer.
 
 

Bear in mind also:
if testing was performed without documented QC, and that testing was used as pretransfusion/compatibility testing for a unit of blood that was issued from your department, it requires a mandatory report to the FDA as a biological product deviation.

Recording it is part of the process.  One of our accrediting agencies (the MHRA) say that, if it is not signed, it wasn't done, and if it is not signed AND dated, it is graffiti.  Whereas, I think that they go well over the top a lot of the time (and few have the guts to challenge them), I happen to think that they are right about this (and it hurts me to say so, believe me)!!!!!!!!!!!!!