carolyn swickard

Where do you get your Trypsin? Could you share that SOP? Since it destroys far fewer antigens (correct?) - would it be ok to use just that for DARA patients? Is it commercially pre-made or do you have to "make it up" also like the DTT? Or does the Hemo-Bioscience DTT come "pre-made"? I know someone else already asked that, but I don't see an answer yet? If it is "pre-made", can you aliquot it to small volumes so you could just treat one set of cells at a time for use that day? Will it last that way? Someone asked if you use 1 ml of DTT to treat 25 ml of reagent cells - how do you even get that much reagent test cells? Our DARA pts have varied widely in how often they have come in. Our first 2 were frequent fliers for a while and even the Dr was surprised and dismayed at how long we could still pick up the DARA - 3-6 months after discontinuing the drug, according to current literature. Our 3rd DARA pt we have only seen once - it all might depend on where they are in the disease process before they start the drug. Newer cases will get a chance to start on the drug earlier and might not be as sick to start with as our 1st pt was. Any answers would be appreciated. This is not fun for smaller facilities. Drs hate waiting for reference lab workups, but they don't think it necessary to even notify us that they have a new pt on DARA either, so we could start a workup earlier - they just send a Type and Cross for "TODAY!"

Thanks for the help everyone - I think we are going to stick with glass, but Fisher Sci is having shipping problems in this area (USA Southwest) and we are getting a lot of broken tubes. I was having to explore the plastic tube option again.....sigh. Yes, we read several things under the scope with "tube rolling" - probably always will. It is very difficult to correlate an antibody found on Solid Phase with any of the tube enhancement medias , including PEG, so sometimes you need help. Also DATs (looking for mixed field) and Fetal HGB stains need the scope too. As for the static issue - maybe this will help others - we purchased a Static Master Ionmaster 4060R years ago that helped tremendously. With the gloves, the synthetic coats, vinyl chairs and the dry southwest air - you can imagine what our problems were. The StaicMasters Ionmaster comes from NRD, INC http://www.nrdstaticcontrol.com/ - look at the 4065 or 4067 now. They are a little expensive to start and require a yearly recharge of ionizing strips (check prices so you don't get surprised), but when they are turned on and blowing over the bench - forget about static. They may recommend something else by now for bench applications. If our little fans ever quit, I will ask about something different from them. Thanks again. I love this site.

Can anyone tell me what kind of plastic tubes are best to use for Blood Bank? Are they optically clear enough to read under a microscope (still in the tube - not transferred to a slide)? If you changed from glass to plastic - that would require validation , right? Extensive validation or minimal? Any help would be much appreciated. We just tried a general purpose plastic tube from Fisher Scientific, but couldn't see very well when we put the tube under the scope.

Does anyone have an SOP for this specific product that they would be willing to share?

Quote "All in all.....a good purchase. My only outstanding concern is some missed weak antibodies (which we will continue to watch for.....for now, every questionable antibody screen will be repeated by Tube PeG). " Wait - are you saying that some weak antibodies that you already knew about or suspect from weak reactions, are not being detected at all by the new analyzer? Is PEG finding them and allowing you to identify them or is it mostly trash?

Just to bring patient variability back into this conversation - we were repeating the antibody ID on a new titer specimen to see if the antibody remained the same (anti-E) - our current procedure. This time around the pt also appears to have an anti-Dia too - not always detectable on our current screens and panels. Testing of the current and previous specimen showed that the anti-Dia was there last time too and was even higher than the anti-E titer (4 for anti-Dia and 1 for anti-E) for both specimens. Fun with patients every day.

Our nurses hang the blood in-house at whatever temp it is by the time they make it back to the floor - cold or warming slightly. They must hang the unit within 30 mins of issue and transfuse within 4 hours of the unit's issue time (all recorded on our Transfusion tags). We only transport in 1-6C packaging if going to our outpatient oncology unit (across the parking lot) and/or if more than one unit is going out at a time. The units left waiting for transfusion (when we have issued more than one unit) are kept cold in the transport container (check the Pelican Biothermal Credo line of Products - especially the Series 4 O.R. Igloo container, 2 liters) and would be acceptable back into inventory because they have been kept at the correct temps. If you only ever issue one unit at a time, the RT transport should be OK, as long as the unit is given within 4 hours, but it would not be acceptable back into inventory. Anything leaving the building definitely needs controlled temperature transport. Does this help?

Are you saying that your nurses want to wait until the unit is "warm" (RT)?? Is that why they would wait another 30 mins if they received the unit in 1-10C packaging?

This might be useful too. I remember reading about a "super DAT" test on this forum, but have not been able to find it again. Does anyone remember how to do it? (I think it involved an AHG phase.) Concentrating the DAT - which I believe this procedure did - might be a good test in some of these situations (symptoms present but the DAT looks negative).

Since we also do a DAT on each of our cord bloods that we test (O Pos and RH Neg moms only) - it just works best to wash all the tubes and do the testing all at once. You have to wash the DAT at least 3X.

EXCEPT - for cord bloods - they ALWAYS have to be washed at least 3 times! I was just doing one and noticed that we forgot to mention them as the exception to the "rules" being discussed here. For adults - I do not wash - just make a 3% suspension in PBS from 1 drop of packed cells. I always do tell my students that if they use too many drops of packed cells, they should wash 1 time at least. For cord bloods, I make a 3% suspension and then drip that out to the test tubes (1 drop each) and then let the cell washer wash the those tubes 4 times. Very easy. (But it always requires telling the students that they must not wash the 3% suspension directly in the cell washer!!!)

Hi - can you describe how you "remove the ADSOL and replace it with FFP" - does it involve a refrigerated, validated, etc centrifuge for RBC units? And absolutely - keeping a whole team "trained" and competent on this procedure is a nightmare! Especially when they call and get us all excited and trying to get everything ready and then they do one more T. Bili and the baby is going to be OK, from all of the hydrating and Bili lights they have been using, without the transfusion. Don't get me wrong - I would much rather skip the whole thing, but the work just getting ready for an exchange transfusion, before you even touch the units, is extensive and either involves a lot of phone calls or a trip in. And they are still doing it too rarely to maintain competency.

We have discovered with ADSOL units that we can add very little (7-10 mls) of FFP in order to stay close to a 50-55% HCT., something I have tried again and again to inform them of, but they don't seem to understand what it might mean for the coag factors for the baby in a full exchange transfusion. Our blood center is eliminating CPDA-1 units as much as possible, and that seems to be OK for small volume transfusions, but it bothers me for exchange transfusions. Do your neonatologists have a "reason" for wanting ADSOL units for exchange transfusion? Could you share it? And based on your calculation formulas - is 7-10 mls about as much FFP as you can get into an ADSOl unit too?

Have you tried searching the PCI reports for medications. If you can get access to PCI and search by patient name, there should be a list of Meds given - depending on how active Nursing and Pharmacy are in your Meditech system.

Yes, that is a good compromise and it is important to know whether they manage to give the unit or not, because in the States at least, you can not charge the patient for a unit they do not receive. This is more like what we have also done in the past. We do not re-enter the unit in the computer though. We simply store it in the refrigerator with the original issue paperwork and hand it back if they come back in time to get it into the patient in the original 4 hours on the original slips. (Spiked units stay on the floor.) If they don't come back - we have the unit and paperwork for proper crediting, paperwork and disposal. We have had this procedure in our manual for years and have not been sited by CAP, FDA or (now) Joint Comm. It happens so rarely that it is hard to keep everyone "competent" on that policy, but it always requires a lot of communication with the transfusing RN because they are worried and nervous too.

How would you titer a negative? Do the negative tubes at the end of the titer (when you exceed the titer) count as negatives? Did this refer to RPRs - sounds like the inspection requirements for RPRs - a graded positive set of controls and a negative control. But even with RPRs, once you are titering, there is no true negative control (until you pass the point of patient reactivity).

Can you let me know where you are sending your testing and how long it takes to get back? Also - how clear is the report - clean answer or so much molecular verbiage you don't know what they mean?

We weigh each one of our units before issue (for the RNs input/output numbers) and our ADULT units range from 270 ml to 420 mls - a huge range to begin with. The small ones are the pheresed units. So - we base our decision to issue the remaining amount of a pedi-pak unit on the weight of the unit. If it still exceeds 270 ml and has been handled correctly, we will give it to an adult. After all, it is no smaller than some of the ADULT units our distributor sends to us to begin with.....

We started a whole new OB protocol a while ago and they were drawing Type and Holds or Type and Screens at the discretion of the Dr based on the pt's situation and risk level. Having all of those Type and Hold specimens was not my favorite thing, but we mangaged a filing and tracking system that meant we could get a hold of them for testing for 72 hours if needed. Funny - several were changed to a Type and Screen 2 days later as the pt."s statuses changed. The OB Drs decided that 35 minutes was too long to wait if that specimen became needed (we have an ECHO) and now they pretty much order a Type and Screen on everyone. We are taking higher risk pts now as we bring our Neonate unit up to a higher level. Also, you never know if the antibody screen might be positive and that would really throw them for a loop. If the baby comes before they get all of their initial assessments and draws done (we are a border hospital), the Type and Screen is usually cancelled if there are no bleeding problems. We only do the Cord Blood on baby 1st and the Fetal screen on Mom (if the baby was Rh pos) for postpartum work - as long as we know the Mom''s blood type in our system - and now most moms have that pre-delivery Type and Screen (yeah!). This new policy allows us to have a much better history record on our patients. It is important to remember that, even though most of these Mom's Type and Screen don't get used - this is one pt population that can really surprise you and they can do it in a hurry! The biggest bleed we have had in years came out of this population with almost no warning that she would have a problem.

If your blood supplier can supply you with a unit that has extra (pedi) bags sterile docked to the original unit (we get one with 4 pedi bags attached) - you can do aliquots for babies without all of the needles and syringes. Also the entire procedure remains "sterile" without introducing any needles or spikes to the original units. You do have to have a tube crimper set or a tube sealer to seal off the pedi bags (I finally got one of the Terumo T-Seal II units - wonderful!!). We photocopy the original bag label, make all alterations to that label, as needed, and tape it to the pedi-bag. It has worked out well for us and no inspector has cited us yet. And yes - one inspector did point out that we had to add the reconstituted RBC/FFP exchange transfusion units to our FDA registration (we already had one for Irradiation), even though it is not one of the choices listed on a FDA rgistration form - we had to write it in. We had to bring the whole team back up to speed with that procedure (YUGH!), only to have them use it once in 2 years so far!!!! They call down and want you to get everything ready and then the current, very effective treatments for high bilirubins get the bilirubin turned around without the transfusions. Thank heavens the babies don't have to go through that, even if it scares us to death every time they ask for this stuff. I constantly wonder how they keep their competencies up on this complicated procedure.

We used to deliver the 1st box only on an ER bleeding episode - helped us to deliver and get the Emergency Release form to the right people and sometimes even signed. The last few years - ER has managed that run. We are so short staffed now that I have even had to ask the OR to start picking up for the heart surgeries too (we used to deliver just for the heart surgeries). We can no longer manage that and keep the Blood Bank going for that patient and the rest of the patients too. OR doesn't have a lot of spare people either, but at least they have more than one person up there!

None yet that I have noticed, but we do most of our work on the ECHO, so have not worked too many patients with this Trio.

and may we all send our best wishes to the poor Blood Bank and techs dealing with this antibody......

Thanks Linda for the info. When we first started irradiating units here, we were taught by the Irradiator company (by way of a cooperating Blood Center) how to label the modified units and we line out the UBS FDA license number on our units too. We have had several inspections and the FDA has never corrected us. The reasoning sems to be that whoever modifies the unit "owns" responsibility for the unit since they have performed a modification on the unit that can affect the "safety, purity or potency" of the product. Your operation of your facility drawing the unit first and then asking a distributor to irradiate it, may fall in a different category altogether.

MERRYPATH - which FDA Registration number do you put on your labels - the FEI number or the CFN number? I have even asked the FDA inspectors which to use and have not received an answer. Can you tell me? Thanks