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Posts posted by Ward_X
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6 hours ago, Malcolm Needs said:
Well, for the simple reason that 1) you have to prove that the reverse grouping anomaly is really just due to the "cold" auto-antibody, and not to something else, and 2) that there is no clinically significant atypical alloantibody being masked by a "cold" auto-antibody of wide thermal amplitude.
True! I was once doing a workup that had both an ABO discrepancy and a positive screen, and they had to be treated as separate issues unless later proved related. Prewarming failed, so another tech following up after my shift had to use cord cells to clean up that mess. The antibody ended up being a non-specific CAA.
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Seems unusual. I've only seen crossmatching the segments of the units that the pt ended up taking from the emergency release. Once our T/S is done we start sending type specific.
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The whole point of washing RBC products is to remove residual plasma, therefore to verify if said residual plasma was removed, you test the washed RBC supernatants for protein.
We have three COBE 2991s and we use Albustix protein dipsticks for detection. We have a positive control made from diluted donor plasma, and a negative control that is just saline. We sample a segment from the waste line post washing. For positive control you should have a set reading to match based on your protein detection technique, the negative control should be negative, and the washed RBC supernatant should be negative or near negative.
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On 10/22/2019 at 12:33 PM, kaleigh said:
Would anyone be willing to share their SOP's for "tubing" blood products? I am trying to get this started at my facility (even though it seems like everyone else has been doing it for years!) and am already getting lots of questions. I figure being able to explain what others do might help! Thank you in advance!
Edit: we do not have the capability of "secure send" or scanning units/badges with our tube system
We only have secure send for two locations, and they're both ICU. Does anyone know if that's a requirement to have otherwise? Besides the fact the station just alarms when products come through, why else would you need secure send?
6 hours ago, David Saikin said:Why is the blood getting warm a problem (how warm is too warm)? It's signed out; it's going to get warm. The tube is not storage. Don't need to maintain storage temp.
It's not that the tube is storage per se, but I guess it's more about how the civil structure of your building is designed? Some of our tube stations are far -- you don't want to expose products to extraneous temperature fluctuations and have them susceptible to bacterial contamination. So sure, once the product is issued it's not entirely the BB's responsibility to keep it cold, but you don't necessarily want the product falling too far from that range before it gets to the patient.
I'm sure the actual physics and pneumatics and all that jazz for how its able to lift and keep suction is more on the engineering side, but I know my facility had to validate all the locations we would attempt to send products. We had techs on each side of sending/receiving at the tube stations and tested the temp. of the products. We even have a floor that is RhIG only via tube.
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40 minutes ago, John C. Staley said:
Good point David, My first thought was, "why is your tube system so slow?" Granted I have a fairly limited exposure to tubing blood but in what experience I've had I've not seen a tube system so slow the blood would get out of temp during transport.
Tbh I'm also somewhat limited in my tubing expertise, but from what I've gathered, our hospital has a boiler system between floors 7 and 8, so the products would kind of get nuked on the way up...
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3 hours ago, Neil Blumberg said:
Even then, I'd recommend tranexamic acid and/or DDAVP, and possibly fibrinogen concentrate (or cryo) long before transfusing plasma and platelets to bleeding patients, based upon randomized trial evidence to date.
This! I don't think consulting a hematologist is even on the care team's mind in terms of these bleeders, which is unfortunate, because if there is an underlying coagulopathy that isn't being treated the products will just run right in and out of the patient with little to no benefit. I guess in terms of traumas, doctors assess the needs for blood and know that's how to save them at that point. Obviously send them RBCs first, but after using x amount of products, what about tranexamic acid!!
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If they have a historical type on file, you do not need a current T/S to issue plasma and platelet products. For RBCs you do need a current T/S.
- gagpinks and Malcolm Needs
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First, I would educate the trauma team on the differences between an actual MTP (in terms of products prepared, and the fact its >10 products in 24hrs), and regular emergency release. That's not to say to ever deny them a protocol if they call for one, but from firsthand experience when I receive a call asking for the phrase "Massive Transfusion Protocol," and I verify what products they will be getting, they don't actually want the sheer number of rounds/number of products listed in our MTP. These areas just know an MTP will deliver products stat, and with relative ease. So, in that case, having pamphlets, posters, what have you, in their areas would be beneficial, as well as explaining about regular old emergency release options (i.e. maybe they only want RBCs, but they only know about MTPs, so they call for that). Just explaining to them that this is an option may reduce the amount of products you're issuing compared to the products they end up using.
That being said, our MTP states our first round is 6:6:1, and then a subsequent round is set up after that, and additional rounds in the same 6:6:1 ratio as needed. We are also a Trauma I center, so our numbers might be higher than yours. However, there have been studies, particularly driven by the US Army, about the "optimal" ratio of RBC:plasma:platelets. If you're worried about platelet wastage, that is an honest concern, but in true MTPs, massively bleeding is still massively bleeding; in which case the products may just dribble out. At the end of the day, it's about pluggin' holes and treating the underlying coagulopathy.
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2 hours ago, ANKling said:
Ward_X we do have the function with SOFTBank but ours is currently turned off since we need the patient account first before being able to issue. I’ve been researching ways around it and hoping to find a work around.
Is there a sort of alias/admission MRN that can be created upon the pt coming to the hospital, that can later be merged? We use this with EPIC, they get an alias name and MRN that we can use for issuing until it is later merged with their real ID. We have names generated that avoid using Jane/John Doe.
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1 hour ago, ANKling said:
Ward_X we have a similar process as you except we have a 3 page carbon copy MTP form and we hand write the unit numbers. As you can imagine, writing a bulk amount of numbers quickly can result in errors. Do you just place the unit labels on both copies of your trauma sheet? Thanks for the reply!
Yup! On each sheet of the carbon copy packet. We also have a barcode replicator (BUI) to copy and make scan-able unit stickers if we needed (although seldom ever needed).
I'm used to HCLL, where emergency issue is sort of a separate function from regular issuing... does Softbank not have this capability?
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I like the sound of the insulated bags, actually
We just use high-density opaque white bags for issuing in-person pickups, and clear ziploc plastic bags for issuing products through our pneumatic tube system. The theory is that they'll get the product and issue within 30 minutes, but sometimes we do get returns and they fail temperature check because they were placed on countertops or wherever they land up in room temp...
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As far as my interpretation of this standard and how my facility operates, the training is not the same thing as the competency testing. Each area of the lab has an initial competency testing, then the 6 month, then the corresponding annual along with everyone else. I don't think mere completion of training without an initial competency assessment is sufficient. Training is often just acknowledging the trainee has been taught a task and can perform said test; the competency is a pre-set blind sample that already has a determined result, so you can tell if your trainee is passing/failing the competency.
I would say: sign off training, sign off competency, then you can perform solo testing.
There is a previous thread here, and another here about GEN.55500 that may be helpful?
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I'm in a trauma I center with an MTP policy that was forced to update post mass casualty. We set up MTP packs ahead of time and have them at the ready for any moment. Each pack is distinguished by gender (O NEG set up for females, O POS set up for males), and is complete with 6 units of RBC, a carbon copy form, cooler card, and pulled segments. The carbon copy form has the record of the unit numbers, but we use stickers from the unit itself. The only info really handwritten is the ABORh of the units, the product code, and the time/date whenever the pack is issued to a patient. Since the pack is set up ahead of time, one tech prepares the pack and a second tech verifies that the units are in an acceptable status to issue, and that the pack is overall assembled correctly -- therefore reducing a number of potential errors. At time of issue, we use ADT labels printed from EPIC that include the pt's information, and this sticker is applied to the carbon copy sheets and the BTRs already tagged to the units.
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We don't ignore the "weaker" agglutinations -- we still record M reactions... however, the result of the titer is the last dilution that is graded >M (i.e. is graded 1+). We have a test result called "below titerable levels" for a titer that doesn't have reportable results similar to what you are describing.
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On 9/18/2019 at 4:26 PM, Mabel Adams said:
The BBIS records should meet US regulations. Our BBIS could print a report of all antibodies if we closed and needed to give that to lawyers. We always do data conversions when we change BBIS vendors. Reviewing old panels and testing records is sometimes informative so we keep them and try to weed out those who have died. Familysearch.org has a records search function that may help. You have to create an account I think, but it is free. They also have a family tree search and usually won't publish a record on someone still living. The people in that tree will have records attached to them, that are probably even correct! They connect with Find-a-Grave and BillionGraves records too.
Is there a way to verify that information is correct? You're otherwise relying on a third-party data collection service, so I'm just curious how we can use sites like Ancestry or BillionGraves
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On 9/19/2019 at 4:31 PM, StevenB said:
Any questions Ward_X or are you "good to go"?
If you have resources, I'd still be happy to take them.
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My lab is also partnering with a transport transfusion service and I've wondered the same thing.
- Perhaps you'd need to register the pt regardless just to document the use of units or,
- The chopper should only have blood on it from the particular hospital that it would transfer pts. or,
- Operate like you suggest and make transfers to that service (however, how do you document proper transfer physically?)
I would say if you're transfusing in the chopper (sort of a middle ground, under the jurisdiction of your hospital), you need to document that a pt was transfused under your control, just at a satellite location. The pt being moved after transfusion to another facility doesn't mean Facility #2 has to deal with the units/transfusion... does that make a sort of sense for sake of discussion?
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You're mainly going to receive input on the laboratory side of things, not so much the nursing administrative side. There's really only guidelines on the timing of the start of transfusion post-issue from the Blood Bank, and that's really just for temperature acceptability & storage conditions...
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We've caught misdraws twice the last month from samples that required a 2ABORh/didn't abide by proper electronic collection... it's safe to say the hassle is beneficial!
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11 hours ago, exlimey said:
This is a very interesting thread, partly ethics, partly practical use of resources, and a large dose of "what if". In the legal sense, the concept of "Prior Restraint" comes into play - doing something to prevent a possible event regardless of probability.
So.....a not-so-unrealistic scenario:
The hospital has a patient with anti-K and is required to screen/type a number of units to fill a transfusion order. During the process some donors/donations are identified as K+. What should the facility do with those, knowing full well that they may stimulate an immune response in recipients ?
And.....discuss.....
Anyone can have their own individualistic ethical standpoint (for example, in my day-to-day life I'm an act-utilitarian), but in the scheme of healthcare you have to abide by Hippocratic/care... therefore you just can't give blood positive for a clinically significant antigen to a pt with that antibody for giggles. It would have to be life or death, or under the jurisdiction of the BB MD to decide. Of course, sometimes in emergency situations, or if you have an unknown pt getting released blood and it turns out they do already have an antibody, that's all down to the ordering physician to adopt the responsibility of knowing the risks. On a tech basis, I don't see any of us just being like, "welp here you go, have some antigen positive blood!"
I'm not sure if this anti-K argument can apply, because that is already a pre-identified, reacting antibody. Of course you would try to give them BKN blood. When we antigen type for a pt and have a batch of 10 units for example, and 1 of those units is K+, the pt with an anti-K wouldn't be getting it. The unit is marked with a tag that lists positive for K, and you move on. The difference in this thread here is that we'd be trying to assume this anti-K pt could make an antibody to another antigen along the way, and whether to screen for this unformed antigen before giving them a unit. It's guess work, and almost retrospective.
On 9/4/2019 at 3:13 PM, Malcolm Needs said:Well, yes and no Mabel. Anti-c and anti-E grouping reagents are very easy to come by (if expensive), whereas reagent quality anti-V and/or anti-VS are both like hen's teeth, and so it would be MUCH more difficult to ensure the units are V- and/or VS-, unless you can check by molecular techniques (Leu245Val).
The point about anti-V/VS is an interesting one, and definitely dependent on the population... but I agree with @Malcolm Needs in the sense that it's extra work for an unknown benefit (at least in Western countries).
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On 8/26/2019 at 7:53 AM, Malcolm Needs said:
Ward-X, if you go to the Library in Browse, click on Educational Materials, and go to page 3 of 4, you will find, near the bottom, a PowerPoint lecture entitled, "Laboratory Investigation of Autoimmune Haemolytic Anaemia" that I submitted in December of 2006 (a bit old now, of course, but still fairly relevant), you will find a bit about adsorptions from slide 50 to slide 57, and there is a Word document that accompanies the lecture explaining some of the slides.
It is by no means the "be all and end all" of explanations, but it may help a little.
Although this mainly covered the preparation/reasoning and less so the conceptual basis, the latter slides from 60 on were quite helpful. Thanks!
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Polyclonal anti-sera (IgG and C3d) on the post-reaction specimen. Positive results then require performance of a differential DAT.
Aliquot Labels
in Computer Systems / Software / ISBT128
Posted
We apply the 4x4 horizontally and wrap the bottom part of the sticker around to the other side of the aliquot.