carolyn swickard

Be careful with monoclonal source reagents vs. human source reagents. The monoclonal reagents frequently do not react at all like "normal" antibodies. We have some that would not react at AHG phase at all, though they reacted at I.S. as per their normal use instructions. Many of our pt's antibodies are so weak any more we are having real problems coming up with samples for students.

We have an extensive review procedure, but O.R. does not participate either in the pickup requirements or the transfusion documentation form (even though they get the same form as the rest of the hospital). When we started our new procedure, it quickly became obvious that it did not just fit their needs or procedures, so mostly they just document "see anesthesia notes..." We are living with it.

We have chosen not to do our unit retyping checks on the ECHO, partly for this reason (our retesting is the bare minimum), partly because we would have to reprogram the computer to accept the new patterns (not impossible, but time consuming considering the revalidation and such) and mostly because unit retyping is much (!!!) faster on the bench than on the ECHO for us. Now, we only bring in 15-20 units a day, I can imagine at bigger centers, with an interfaced computer (our's is not), that it would be well worth the time to just change the patterns and live with the preprogrammed testing patterns (it is a big waste of D reagent though). An earlier post had a good idea - we should all ask Immucor for an update for Rh pos unit retesting vs. Rh neg unit retesting - it's just programing after all - but you would have to keep those units straight! On the other subject raised in this post - you used to find an occasional mislabelled unit (1 every 2-3 years) but I haven't seen one in years since the distribution centers went to computerized checks on the labeling. However, just when you think it is a waste of time to recheck and we should be able to drop the retesting, many more hospitals are going to computer crossmatching. In that case, if the transfusing hospital doesn't recheck the unit, there is no other check going on at all that proves that unit is what it says it is. So, my guess is - we will be retesting forever.

nice list of documents - but I couldn't find this one in the library - did it not "stay" or something?

We just finished loading it - seems to be going OK. We rechecked the daily 3 level QC as required by the update documentation, but we also ran 10 group/screens (5 antibody positive and 5 antibody negative with a random mix of ABORhs). Replication of the testing was very good. You do notice the slightly longer incubation time on Stats, but the rest of the time, we are so busy, we are just happy to have the machine get through the Group/screens while we do everthing else.

We have transport coolers for "storage" in OR, ICU/CCU, ER and anyplace else that might need more than 1 unit issued at a time. The coolers are from Minnesota Thermal and have been repeated validated and are very stable 1-6C. We place all RBCS in the refrig upon receipt and only remove a few at a time to input into computer and pull segments, after which they are returned to refrig. Testing is done and then most units are tagged as "retested" in frig and then moved to "avail" shelves in date order. They seem to stay nice and cool as long as you only work with 4-6 at a time. We check the computer entrys against the shipping document after the units are in the computer. For returned units, we have a possibly weird policy, but it has worked fairly well for us. We take a returned unit and immediately place a Biosynergy HemoTempII on the unit and place it in the refig. We set a timer for 5 mins - no more. If the unit will show a temp on the indicator within 5 mins, we accept it back into inventory - if not, it is discarded. The only exception would be if the floor could still give the unit within the original 4 hours of the issue time. We hold the unit until they can restart - but only if they can infuse within the decreased time. It happens sometimes that they just need something else signed or fixed and then they can get the unit started. The temp indicators have allowed us to save a few units, but the majority still have to be discarded, because, believe me - those units warm up fast during handheld transport. We are attempting to replace the indicators with an IR therm, but that is in validation right now and I don't know if it is going to be as stable or reliable as the indicators. IR therms seem to report a wide range of temps depending on how you use them. Best practice so far - hold the IR therm very close to the unit (possible even touching it) in any area where there is no paper or tape (Yeah, I know - all of 2 inches somewhere on the back of beyond!) and take 3-4 readings and average them. Hope this helps if anyone is interested.

I'm sorry - I don't know - you would have to ask the company. Who "approves" thermometers for blood anyway? What regulations are involved? Which accrediting agencies?

I recently purchased an infrared thermometer and a blood transport container datalogger system from http://www.global-sensors.com/ - they were recommended by the Minnesota Thermal Science - the guys that have the Golden Hour blood transport systems. They were nice to work with and offer yearly calibration services and battery changing and recalibrating of the dataloggers. I haven't needed those services yet, but I hope to have good service when I do.

If anyone can still send a copy of thier audit checklists or procedures - I would appreciate it very much. carolyn.swickard@lpnt.net

We are seeing very few failures for ABORh on our ECHO. One thing we do notice, backtyping is frequently weaker on the ECHO than it would be in tubes, but even 1+ positives will interpret correctly. We occasionally see very small agglutinates in A or B backtyping wells that should be neagitve - the ECHO will fail these interpretations. I wonder if it is a cold or rouleaux that causes these or micro clots in the EDTA specimen? Overall, we are happy with the job being done on the ECHO.

For both posters with Check cells problems - just a question. The Helmer Ultra CWs are highly programmable - is there any chance you are not getting enough saline delivered in the wash cycle you are using? Are you programmed for 10X75 tube volumes or 12X75 tube volumes? Etc... As for the Lab markers washing off - all Sharpies seem to wash off glass, we use a Lab marker from Securline that seems to work well - manufacturer ASPEN (carried by Fisher and Cardinal, I think) and REF # 1400-20 PDC (that might be a product # - not sure) Good Luck

We test the cord bloods from all O moms and all RH Neg moms and any other baby the Dr might request (very rare). We also use a well mixed EDTA specimen for the Fetal Screen test - that seems to be the most logical choice, since we do not know exactly how the mom's and baby's cells might differentially separate as they spin down.

We have 2 Helmer CWs and haven't had any problems like these at all - what kind of saline are you using (possibly too acidic (not buffered?)). How often do you clean your instruments and how do you clean them?

Sorry all - no one seemed to answer this question - if you send two RBC units up in a tube - what does the floor/unit do with the second unit while the first one is being transfused? Do you have floor refrigerators? Do both units have to be transfused within 4 hours? Or what?

Yes - if we start using these - instructions to both the patients and the hospital personnel will be mandatory. We received a helpful card once - 2 days after we had delayed surgery and sent the specimen to a reference lab! Still, I like the idea even if there will be thousands of different types in the States. Also, the only numbers we could possibly use as identifiers would be DOB and SS# - thereby giving everyone another card from which thier identity could be stolen! I would like to advocate that someone like the AABB start a national antibody database that could be accessible using the patient's name and SS# - that would really be useful and it shouldn't be impossibly onerous to input all new antibodies to the database(?!?) I can't imagine what the security would have to be on the site though, or what kind of liability insurance would be appropriate for the agency hosting the database. Oh well.....

We have a slightly different request/problem from our OB/GYN doctors. Some of their patients don't get to them until after they have presented with bleeding in the ER. Our procedure has been to just follow the Er Dr's orders and do only the ABORH and give Rhig if the pt is RH Neg and the Dr requests it. It follows later that the patient is referred to an OB/GYN and then that Dr orders the antibody screen - which is, of course -positive!. They are now requesting that we do an ABSC on these pts in the ER, but they aren't working through the ER Dr's to get the orders for the ABSC. How do you handle having no Dr's orders for a test? New policy? Medical Director intervention? Do you get reimbursed for the testing if it comes from an internal policy and not Dr's orders? And yes - we do a lot of "detective work" trying to find out "Is it Rhig or is it REAL?" I so wish Rhig had some kind of detectable tag you could look for in testing. We use Immucor's Solid Phase testing and can detect Rhig for up to 3 months!

Give me your email address or your phone number and we can get in contact and I'll show you our Meditech Magic build for D Indeterminate and Weak D - the tests can be waiting in the result colum (normally answered with "NP") and only used as needed. 575-521-2202 or carolyn.swickard@lpnt.net

So much of the differences in the US comes from the complexity of the governing bodies (FDA, AABB, state and local governemnts - crossing statelines.....etc.) and the relationships between the hospitals and the blood distribution agencies (also numerous (local, state, national....). Not to imply anything, but size and the distances involved do have a lot to do with it too (think Montana, Wyoming...etc). Many of our smaller, rural hospitals are a long way from a reference lab - everything is flown or shipped FEDEX, etc. My local blood distributor sends reference lab work to another state - can take 2 days to get answers back - ugh! I ship my stuff even farthur, but the reference lab I use (Gulf Coast Regional Blood Center, Houston TX) can get it out in 15-24 hours after receipt (many kudos and thanks to them!!!). Many of the for-profit hospitals have contracts with the huge, national reference labs - Quest, LabCorp, etc - again shipping and waiting for answers. Since some of these labs don't even have blood - of course, they don't crossmatch for the hospital. There are a few regionalized blood centers who solve problems, crossmatch and ship blood back to the hospitals (Puget Sound in Washington state comes to mind). There are many methods for the many regions and states and systems - one kind of answer just won't cover the States.

We take 2 segments off as we issue the units, place them in a cup labeled for each day and have a rack that stores 14 days of the cups. Each segment pair is wrapped with a DIN number from the back of the unit (or handwritten on tape if all the DIN tags are gone). We very seldom have to go back for the segments, but they have been easy to find (we issue around 15-20 units a day) when needed. We do not keep segments for plasma products, only RBCs and have called and had the RN or the OR do it for us on the few times we have forgotten to get the segments. Since the cup is on the issue desk itself, that helps to remind us to get the segments. We haven't had the actual units themselves returned in years - yuk!! One of the segment sealers would probably do a nice job making usable segments for those facilities that do not get them pre-segmented - expensive, but definitely worth the cleaner procedure.

2 cell screens never have cells with the f antigen (they are only R1R1and R2R2) - the 3 cell screens have a rr cell. Anti-f can be quite clinically significant and occurs more often than Cw or Dia, which are also frequently missing unless you order the special screens.

There is a kind of plastic separator that can be added to tubes after the draw and before the spin down that is nothing like the SST gel. It might be usable (I think it is inert), but you would have to get your red cells out first before the separator was added and spun down.

We crossmatch with the unabsorbed plasma and report the units out as "Least Incompatible" too. We have a simple chart form called the "Blood Transfusion Consultation Record" though. We record the problem on the top of the form, record which/when we refer it to a pathologist and the pathologist calls and records the consultation with the attending physician (who/date/time/what was discussed /recommended) and then the pathologist signs the form and we send the original to the pt's chart. We keep a copy in the Bank but have never had to use them. CAP and FDA inspectors have seen the forms, but have never said one way or the other whether they like them or not. The Dr does not have to come and sign the form, but their name is on the form on the chart.

The Immucor Technical Communication really only states that they recommend "buffered saline", not that it has to be pHix buffered saline. If you switch to buffered saline for all of your Blood Bank work, wouldn't that use it up fast enough? We used Nerl buffered saline (available from Fisher and probably Cardinal) for several years before switching to pHix buffered saline after purchasing an Immucor Echo. All of our BB washing and diluting was in buffered saline and it works just fine.

There has been a lot of discussion on this topic in the CAP Antibody Titer Survey. They have presented and recommended tha "standardized" method and we too had a reaction one tube lower when we incubated for 30 mins instead of our SOP of 60 mins. The standardized method also called for unbuffered saline, but since we don't have that anymore, all of our testing was in pHix buffered saline (we use Capture solid phase for routine testing). I don't know if that would make a difference too. The results of the titer surveys have consistently shown a higher titer achieved in gel studies - I assume this is because gel acually has LISS enhancement(?) involved in the method. There are 2 distinct curves for tube testing vs gel testing over and above the curves involved when enhancement medias are used in tubes. CAP has been trying to get some standardization in this test for some time. The CAP AB Titer survey final critiques have several references in them - might be useful. The best article I ever found was a Transfusion article - Transfusion Vol 41, Nov 2001 - titled "Practice Guidelines for Prenatal and Perinatal Immunohematology - revisited". We designed our SOP around that article and have been on the CAP survey mean for tubes since. I really hope they have another conference and put out another set of guidelines in the next decade too (seems to be about how often they do that). Still one controversy even in that article - What kind of cell to use? heterozygous or homozygous for the antigen the mother has an antibody against. We still have trouble with picking a consistent cell depending on the antibody and the cells available to us. The CAP survey just gives you the cell now because they have tried to eliminate that part of the variability in the test results too.

Just a thought - I was under the impression that the temperature of the unit was more important to the FDA than anything else. We started doing Temp checks on returned units years ago and will not accept a unit back for storage if it has exceeded 10C. (Use Hemptemps II from Biosynergy, Inc). We immediately place the indicator on the unit and place in the frig. We set a timer for 5 min and check to see if the unit is within temp range - if so, we accept back for storage. If not - the floor is told they can still transfuse if they can get the problem fixed and get the unit infused within the original 4 hour transfusion limit. If they can not transfuse in the original 4 hours, we destroy the unit. We lose more units this way, but the small pheresied units (usually 280 ml) will not hold a temp <10C for anyways near 30 min. Also, if it comes back cold after being out 30 mins, do you assume it has been stuck in a floor refrigerator? What do you do then? We have the same problem with thawed FFP - it is warm when you issue it - what to do? We have been taking it back for use within 24 hours by the original recipient only, don't really know if that makes sense or not. any feedback appreciated