rcurrie

Don't forget to ask the physician about the procedure. We have had cold reacting only anti-M become clinically significant when the patient was chilled down for open heart surgery.

We had one potent cold agglutinin cause problems with the heart pump, but that didn't cause us to begin checking for cold agglutinins again. Too much trouble for such a small risk.

We only set up units on inpatients. New antibodies on outpatients just generated a call from the medical director to the attending physician.

I believe your procedure is correct. Since the units issued did not qualify for an electronic crossmatch at the time they were issued, then you must perform a serologic crossmatch. BC

Ah, the old shakedown problem. I visited my BB mentor one day. He was working on a transfusion reaction workup. I asked him if it was the usual febrile reaction. He said no, it was a real antibody. It seems that the patient had a 1+ reactivity, but the tech that did the type and screen had a 2+ shakedown. No joke. BC

Great job in increasing the safety of tubed blood, Thad. BC

What Mabel said. I have audited many transfusions, and it is sad to say that I found that in many cases the nurses were doing their "bedside" checks with the unit clerk in the unit station. As Gomer Pyle used to say: Shame, shame shame! Don't bother citing FDA, AABB or CAP- the only thing nurses fear is JCAHO. BC

Kip, High bilirubin was noted in each sample, so it is not a color issue. It may not be a donor issue- it could well be a processing issue. Are these SDP platelets? You may need to recalibrate the RBC detector on a certain apheresis machine (see if the units can be traced back to a certain machine). Are the random donor platelets? There may be someone new in the processing center that is being rough on the whole blood units; the units could be over-centrifuged, thus hemolyzing some RBCs; or there may be some other processing problem. Remember the cardinal rules of traceability and trackability, and look at who handled the units in question and what instruments were used in the processing. I bet you have a processing problem rather than a donor problem. BC

We are a bunch of old fogies who have failed to keep up with social practices. Some of you younger techs out there should have presented the most obvious solution: Blood Bank tatoos. Every transfusion service should have a certified tatoo technician, whose job it would be to tatoo the blood bank ID onto the potential blood recipient. Why has no one thought of this before now ! ! ? ? BC

When I started blood banking many moons ago, we would set up 6 whole blood, 6 packed cells, 6 FFP and 12 platelets for all CABG patients- there was no such thing as a redo CABG back then- your only options if there was restenosis were the type of casket and burial vs. cremation. Back in 2007 (before I changed careers back to railroading), our cardiac sugeons were just asking for a type and screen. Most of the patients went home with no transfusion whatsoever. After following cardiac surgery patients for almost 20 years, I have decided that the best transfusion is no transfusion. This doesn't hold for all patients, though. There is just something different about giving blood to someone who has had open heart surgery. We have all seen the studies, and I agree with those who advise against transfusion unless absolutely necessary. BC

Back when I was in the blood banking business, I was a member of our Level 1 trauma team. When the issue was brought up, I said they could have all the type A plasma they wanted, as I was unable to even put a dent in the bucket with AB plasma. They weighed the risk, and agreed. So, we don't automatically supply AB plasma for our traumas- they get type A until proven to be type B or type AB. It sure beats no plasma at all. BC

Mabel, I have always had great luck with the Terumo sterile docking devices. BC

Shily, you beat me to the punch. Sounds like it could be anti-LW. BC

I am with you, Ada. I never agreed with the CAP ABO repeat requirement. I am still waiting on the pictures of your new blood center ;-) BC

I vote nay on automatic elutions. Get a history if the DAT is positive, and consult with the physician. BC

Thanks for speaking up as a reference lab, Kathleen. Folks, if you don't have the antiserum to type the unit, then let the reference lab/supplier know and have them type it for you. This isn't about retyping- it is about the initial typing, which is not done when historically antigen negative units are supplied. Reference labs are doing two things when they provide such units: saving time and money for themselves, and saving money for you. You can antigen type cheaper than the charge from the reference lab for such service most of the time. BC

John, I still run a railroad for a living, but I consult for a blood bank on the side. Keeps me fresh. Right now I am part of a team that is building a high speed railroad while a low speed (25 mph) railroad is running on the track. So, we shut down a piece of the railroad during the day while about 20 different contractors work on it, run freight trains on the rest of the railroad, and then run freight trains at night on the section under construction. We will run about 70 trains a day when we get things finished. I am over all train operations and I ensure that the contractors are following federal regulations (just like my blood bank work- can't get away from the feds, except that it is the FRA I deal with now instead of the FDA). BC

It's a possibility, I suppose. You were dealing with an oncology patient, and they are so predisposed to transfusion reactions due to their immune status. As QA, I never really had the time to investigate febrile reactions as much as I would have liked to. I always thought universal leukoreduction to be "the" answer to febrile reactions, but found out that this is not so. Oh, sure- it helped. But we still had febrile reactions. I suspect that nearly 100% of our transfused patients undergo some type of reaction to transfusion, but most do not exhibit signs or symptoms that we recognize. After all, we are injecting a foreign substance in massive amounts into their bodies. Are we doing more harm than good by transfusing? There used to be no question about this. Now we are beginning to wonder. BC

The issue is whether accepting "historically negative" units without retyping is a reasonable risk or not. The underlying question is whether the unit is from the donor the system says it is from. No collection-distribution system is perfect. Every time a unit is manipulated in a processing station, it is usually manipulated at the same time as multiple other units. Some processing systems attach a filter after the unit has passed all testing to save the cost of the filter on units that are rejected for one reason or another. This is a point at which units can be mislabeled. Confounding the chances of not catching this error is the habit of processing like ABO units at the same time. Donor A's ABO was A neg prior to filtration, the unit labeled as Donor A tested as A neg after filtration, so it must be Donor A's blood in the bag labeled as Donor A. Anyone who believes this assumption to be true has never worked as QA in a blood processing facility, which I have. There is always the chance that the blood in the bag can't be truly linked back to the donor. Thus, the "historically antigen negative" label is a crap shoot. That said, the issue will always be whether it was reasonable for you to accept the label as true. I can tell you that a jury would not find it reasonable in a survivor's lawsuit. I did a complete flipflop on my attitude toward risk and liability after two events in my life. The first event was when I had to defend my practices in a wrongful death lawsuit. The second was obtaining my law degree. The rule of thumb is that if you could have prevented an accident, then you will be held liable for the accident if you had a duty of any sort to prevent it. Providing safe blood is one of the highest duties you can imagine. Skimp because of cost, and you will pay the price if something goes wrong. It doesn't matter that you were right 99.9999% of the time. BC, J.D.

Our goal in our huge sicke cell population is to prevent alloimmunization. We try to match Rh, Kell, and Duffy in our population. We ask our Hem/Onc guys to let us know when we have a new sickle cell patient, and we tag them in the computer with our protocol. We give blood that is sicke cell screen negative in all sicke cell patient cases. We use electronic crossmatching unless they have a positive screen or a history of one. BC

Why not point fingers, Likewine? You can bet your booties the nurses sure say "the lab messed up". Read a chart sometime- I bet you will find in 1 out of 10 the comment "Lab Error". Until I was placed on the chart review committee, I had the same opinion as you. However, I have seen that "lab error" comment enough, and know that in most cases it is not true, to be driven to the dark side, where we tell it like it is. BC

AABB is a good source for billing help. The next best place is your Medicare intermediary. Intermediaries do differ in what they reimburse. That little-known fact makes most reimbursement advice given on this site of dubious value unless both the asker and the askee are under the same intermediary. Just because there is a CPT code for a procedure doesn't mean your intermediary will pay for the procedure. BC

Do you transfuse outside the hospital, say in an outpatient setting? At my last hospital (I run a railroad now), we sent blood to several dialysis centers, several outpatient hem/onc clinics, and a few home health agencies transfused blood in the home. The regs/standards require that the patient (or attendee) be made aware of signs and symptoms of a delayed transfusion reaction. I audited this and found almost zero compliance. BC

I was taught to grade mf reactions in SBB school (thanks, Clare), and found that grading is very useful with subgroup identification. However, unless your bloodbank staff are all highly trained and mostly SBBs (like my former lab), you may be asking too much of the techs. I think most labs that have techs that rotate in and out of blood bank would be tickled pink just to get techs to recognize mf reactions at all. BC

I suspect that tgriffin is referring to the digital thermometer calibration checks required for thermometers used to qualify donors. The regs do require monthly calibration checks for those thermometers. As the FDA what they require for a variance waiver. That is your best source. That said, I don't know of any donor center that has been given a waiver. Good luck! BC