Mabel Adams

We have been trying to buy a new serological centrifuge but the Clay Adams is backordered for months. All of the vendors keep suggesting others that they think will work. We have already tried a Hettich EBA21 and just can't get it to work as well as the old Clay Adams. We get different results on titers using the 2 different centrifuges. Cell suspensions that are washed in it end up mixed once the braking stops. If we set the brake lower, it takes too long to stop. Is there a good serofuge for sale in the US anymore? I miss the Immufuges of 1985.

We use the CDC guidelines for the pathologist to interpret the reaction workup, not for nurses to determine whether it is a suspected reaction needing workup--not that they shouldn't have such information available. We also quote the JC standard in our procedures that says the workup should be performed if it meets our criteria "regardless of whether the physician deems it necessary".

Once the interfering drug is gone, we would treat them like a usual patient with a negative antibody screen. One caveat is that our BBIS won't allow an EXM for any patient who has ever had a positive antibody screen reported. If we ever reported the initial screen as positive instead of the DTT-treated screen (negative, I hope) we would have to do future XMs by IS rather than EXM. If we knew the patient would go back on it, I suppose we might give K negative units but most that I have seen go off of it didn't go back on and, frankly, most expired within a few months. This experience is mostly from the early days when it was only approved as a last resort therapy so now less refractory patients are taking the drug and may have different outcomes.

Unlike the Provue, newer gel analyzers can allow partial panels to be run.

We can't get our Hettich EBA 21 to do a good job of spinning tubes. We find we get different answers from titers run using it. The cells get mixed up in a manual wash. The vendor suggested we change settings so the braking is less but then it takes forever to stop. My staff wants to get rid of them but there isn't much out there to buy these days. Does anyone have a good answer?

I agree with new pain. I find that the BP question is difficult because of patients being treated concomitantly for either hypo or hypertension, not to mention getting up to use the bathroom or getting riled by being visited by that annoying person who says they deserved to be sick because of something they have done. Or maybe they got the post-op cancer diagnosis during the transfusion. I have heard 30 mm Hg suggested but I think it depends on how it is applied. I look forward to someone having a clear cut answer for you.

Sometimes adaptations are made depending on limiting factors. Maybe time is of the essence because the patient is bleeding or going into major surgery so more panels or methods are run at once to arrive at a conclusion more quickly. Sometimes there is only limited amount of patient plasma so fewer tests are run at a time and further testing determined based on the results of early testing. I always say that after the first panel with usual algorithm for rule-outs it ceases to be as much about the usual rules and starts to be more a matter of judgment and experience. The "rules" help newer people and generalists stay on track. If it gets complicated, they can call on more experienced people, including waking me up at 2 AM if need be.

I just answered this question. My Score PASS  

It helps to spell it out sometimes.

A list of references would be great, if you have time.

What if the anti-Jra is not actually getting onto the adsorbing cells? Could that be emergency room's point? If the eluate does not contain anti-Jra then it would prove that is why the adsorption isn't working. But I would think even a little bit of antibody that adsorbed (even if it is not enough to affect the strength of the reaction of the adsorbed plasma) could make the eluate contain anti-Jra so the odds of the eluate lacking it would be astronomically small.

We have an MTP order set but it doesn't order the blood products, just 99 transfuse orders for each product. Once MTP is called, we enter the product orders in our BBIS (SafeTrace Tx) or use it for emergency issue. Thus all units are tracked. We use a paper log to keep track of what cooler we are on plus some lab values etc. There are downtimes which are still on paper forms. Epic doesn't send blood product orders through the LIS. They come straight from the clinical side into the BBIS. It would not work for us to be able to verify the first order so we can't do your reflex idea but it sounds good.

I hope the lower amounts of plasma in the newer platelet products (PAS and pathogen reduced) will help reduce this risk. We do our best to match blood types but are remote and not that big so have the same problems as others. I am not clear on why avoiding high titer platelet donors is not any help. I think the fatal cases were mostly from high-titer donors, but are you making the case that there has been no research to prove that avoiding them prevents fatal reactions? Or is there actual evidence that avoiding them does not change the risk?

Wise John Judd once advised me to do titers on anti-M antibodies without concern whether it was IgM or IgG. We didn't do DTT testing there. Once the titers reached 16 we could send it out then for further testing to delineate IgG vs. IgM . We had to report it carefully and clearly so it was clear what we were measuring. No titer ever exceeded 16 so we saved a lot of money on send-out tests. Now we do pre-warmed testing on them and only pursue those that react by that technique. Still haven't seen one with a high titer.

There is some value in the need for a provider to stop and ask himself if the need is urgent enough to give uncrossmatched blood. Placing an order, verbal or otherwise, serves that purpose. Getting a form signed after the fact is just bureaucratic blame-shifting, I agree. Someone should propose that all of the regulatory standards be changed to reflect that. Has anyone ever seen someone request uncrossmatched blood whose mind would be changed by knowing they needed to sign a form? I have definitely seen some of them change their minds about transfusing when faced with signing our "increased risk" form for transfusing patients with, say, a warm auto, high retic count and Hgb of 6, but maybe that is because we provide more information about the risk when we complete the form.