Virginia

Malcolm, Thank you. It 's a rare advantage to gain access to the data gained from the number of AIHA patients that your lab has seen. David, It's true that we are not a reference lab and don't have the cells needed for allogeneic adsorptions. We autoadsorb with the PEG procedure, discovered in this forum. We much prefer it to Immucor's WARM which we had been using for years. XM's for warm AIHA patients are usually incompatible with unadsorbed plasma and we call them incompatible. My 'in vivo' reference describes the reality that transfused RBCs cannot be expected to survive normally because of the patient's autoantibody. Autoadsorbed plasma may give negative antibody screens and XM's. While this information is valuable, XM's are compatible only 'in vitro' and could be misleading to primary care physicians. Our release form states: Incompatible transfusion/compatible with autoadsorbed plasma, and we give each physician a copy of 'A physician's guide to transfusion in autoimmune hemolytic anaemia, written by Lawrence Petz, M.D. Sorry about the confusion.

My (fairly) small hospital has several oncology services which send over a fair number of patients with warm AIHA. We do the usual work-up including DATs, Ab ID, and elutions to establish a putative diagnosis. We autoadsorb with PEG when applicable, if the patient has not been transfused within the last 3 months, but since the crossmatch is still incompatible "in vivo" we have MDs sign for transfusions. My question is: how often do you think it necessary to repeat elutions showing a panagglutinin...72 hours post transfusion, weekly, monthly? Advice will be much appreciated.

Favorite diagnosis: Cabbage

Thanks for all the good input. We shall be happy to give up all of that scribbling on stickers.

Is anyone still putting "Type & Rh Confirmed" stickers along with the date on blood products received from your blood center? Now that these data go into the computer, the stickers do seem superfluous.

Mary, Thanks for pointing out the reagent package insert limit on specimen age. We have always used 10 days because it seemed right, but now we have a peg upon which to hang our policy

I agree John, that Biotest's e-mail was a bit opportunistic, but that's business. We were a good bit more annoyed by Ortho's and Immucor's outrageous price increases in the last year. Competition in the marketplace is a always good thing, and we have had very few choices in the last decade. Gin

We have been using Biotest reagents for 3 months and are well pleased with them. In our comparison studies they performed as well or better than Immucor reagents and prices are much better. We were glad that we made the switch before Immucor's run-in with the FDA became known.

Lara, If you would be so kind, I would also like to see your Q.M. plan. My e-mail is at virginiar@unionhospital.org. Many thanks, Virginia

Krichards, thanks for the info; could you also fax me a copy at union hospital blood bank 330 364-0862? Virginia

Thanks for all the good replies to our question about RhoGAM for Rh positive platelets. The information about (recent) patients making anti-Rh has convinced us that giving RhoGAM prophylactically remains a good idea for us. It is not uncommon for our supplier to have shortages of Rh negative rbc units, to the point that occasionally an Rh negative patient may have no other option but Tx with Rh positive rbc's in a big bleed. If that patient already has anti-D, he has lost the one chance to receive the Rh positive rbc's which might save his life. Again, many thanks for sharing your experiences.

We have always given RhoGAM to Rh negative patients who must receive Rh positive platelet concentrates, it seemed prudent. Today platelet concentrates have fewer rbc's, and I wonder if anyone else thinks that perhaps this is an unnecessary precaution. Any comments would be appreciated.

It's clear that some blood banks are too large to permit the occasional transfer of information between technologists and nurses. We consider this interdisciplinary dialogue to be of real value in providing safe transfusions. Also repeat types do have value. In a perfect world technologists would never be distracted from their work. However in smaller labs techs must answer phone calls, issue blood, and deal with suppliers, shipments, emergencies, etc... Handling all the details that make a transfusion service run involves a lot of interruptions, and it is not impossible to imagine a mistype due to loss of attention. Retypes are cheap insurance. I believe that CAP's new TRM.30550 reflects their espousal of some of the key principles of W. Edw. Deming, widely respected as the father of the Quality revolution. Some of those are: 1. Cease dependence on mass inspection to achieve quality. Instead, improve the process and build quality into it. 2. Break down barriers between departments. People must work as a team to foresee problems. 3. Eliminate exhortations and targets asking for zero defects. They only create adversarial relationships, as the bulk of the causes of low quality belong to the system and thus lie beyond the power of the work force. In other words, people are only human, and the best trained and intentioned individual can still make a mistake if the system is not designed to prevent it. We shall continue the search for an answer to TRM.30550, perhaps it will be the "Blood Lock" described by James AuBuchon in TRANSFUSION, Vol 46, No 7.

I think that anyone who would not notice the difference between a spun tube of blood with a 5g Hgb and one with 16g probably should not be doing crossmatches. A discrepancy like that should always be questioned and resolved before any blood is issued, let alone 4 units. Our separate BB bands are invaluable when patients come into ED without any identification, sometimes in groups. It may be true that different manufacturers use the same resources for antisera. However few techs realize that, and are more likely to do that retype than if it was just a repeat with the same reagent. We usually have only one tech working in the BB, so repeat by another tech is not an option. I agree that this does not solve the problem of patient misidentification, and am still searching for alternatives.

Has anyone had a successful CAP inspection since they added the new question TRM.30550 about misidentification of pre-transfusion samples? We have always put a BB specific bracelet on each patient when a sample is collected and the bracelet's number goes on the sample tube along with all the usual data. If the patient is not in our file, we have been retyping that sample with reagents from an alternate supplier, ie. Immucor vs Ortho. The nurses then must compare the number on the BB bracelet with the same number on the unit tag before beginning the transfusion. I wonder if our BB bracelets would satisfy CAP's reference to a "mechanical barrier". Does anyone have other suggestions, and have any been approved by CAP so far? We have considered using the "Bloodloc" bag made by Novatek, but worry that nurses would just cut it off if they had trouble opening it. Thanks for any good thoughts.