Mabel Adams

John, it's hard to believe that you have to explain who you are after all these years but I guess there are lots of newbies and you aren't on here as much as you were "back in the day." We've probably been talking online for over 20 years now. Wow! Remember Y2K??? We probably hashed that out together online.

We are a system of 4 hospitals and we collect a new specimen when the patient is transferred to the bigger site. We use a blood bank banding system and the ED is instructed to cut off all bands a patient comes in with so that would make the original sample unusable by us. Also, if serologic crossmatches or a transfusion reaction workup are needed, we need a specimen here, at our site. Besides that, we are not responsible for training and competency of the testing staff at our small hospitals so would not accept responsibility for their work. We share a computer system so historic blood types count toward electronic crossmatches but we would want the patient ID to be for this facility for the specimen of record. Many of our transferred patients are emergencies and the logistics of getting a blood bank specimen transferred here in time to be of use for the patient make it pretty much impossible. We also don't want nurses to start thinking that it is okay if ID numbers etc. on patient bands don't matter in cases like this so they end up ignoring them on other cases when there is an error. We do allow pre-ops to be drawn at any system draw site because have a consistent phlebotomy competency program across all sites.

Ortho provides a template DAT procedure for gel you might want to look at. We now do our cord DATs in gel, on the Vision mostly. We have long done only IgG DATs on cord blood so use the IgG cards for this.

So what do all of your hospitals do for plasma, stock thawed, liquid or only frozen plasma?

If a unit is issued at, say, 2210 and the specimen (not the unit) will expire at MN, do they have to stop the transfusion at MN or is it okay to finish giving the unit if it isn't quite done by MN? We use MN on day 3 as our crossmatch/specimen expiration (not exactly 72 hours) so theoretically a specimen even in normal circumstances could be over 90 hours hours old at the time of a transfusion if it was drawn very early in the morning. I am convinced that medically it won't "turn into a pumpkin" at MN but what do you think inspectors would say? Do you have a hard and fast policy for this or leave it up to judgment? Is it okay to issue a unit on an expiring specimen as long as issuing occurs before the specimen expires, the infusion will start by the time the specimen expires, or only if the entire infusion can be completed by the time the specimen expires?

As stated above, we use IS XM for ABO compatibility check only when the computer is down. We have passed several TJC and AABB inspections since starting this. Here is a quote from my crossmatch procedure: Whereas: Sensitivity: Immediate Spin crossmatch will not detect 100% of ABO incompatible units due to low titer of antibodies or weak expression of the antigens. Specificity: Immediate Spin crossmatch gives some false positive results (cold agglutinins, rouleaux etc.). Cold antibodies can cause false positives with immediate spin crossmatches, presenting a quandary on how to manage a unit that is incompatible at IS and compatible at AHG. Warming the sample to avoid the cold antibody might reduce the reactivity of the ABO antibodies as well. This false positive could happen even with an O unit when ABO incompatibility is not even possible. The BBIS contains algorithms that verify the ABO compatibility of all products selected and our validation shows this to have 100% sensitivity for detecting ABO incompatible units and 100% specificity for avoiding false positive results—both an improvement over immediate spin testing.

How are Critical Access Hospitals dealing with the need for plasma in MTPs? Do you use liquid plasma? Keep thawed 5 day units on hand or thaw on demand and have to come from behind on keeping a 1:1 ratio? If you have a specific protocol that covers use of TXA or cryo at these locations to make up for not having platelets & thawed plasma available, I would love to see your procedure.

Two years later, I have the same question. What HCPCS code is everyone using for liquid plasma?

We follow pos gel screens in these patients with saline screens and have found some negative. Our standard saline screen includes a 37C phase but we are building a new DTT screen test in the computer and are trying to decide if it should include the 37C phase. Our reference lab had said that they don't do 37C on DTT treated cells so we were building it as AHG only but now we have learned that they do 37C with untreated cells for these cases (because they do numerous panels and other testing as part of their standard workup rather than just a DTT screen as we would do). I see from our user group that some are using PEG but we haven't validated that. How many of you are using PEG for testing DTT treated cells?

For those of you doing antibody screens on DTT-treated cells, what phases are you including? We don't usually do IS on screens so won't do that, but we are debating reading at the 37 degree phase vs. just doing IAT only screens. We would be testing treated cells by a saline method with a 30 minute incubation. We are getting molecular antigen typing done on the patients for whom we get pre-treatment specimens. Our usual testing method is gel but not for the DTT-treated cells.

The report from the allergist included information from a conversation with a transfusion medicine physician at the local medical school who apparently mentioned the possibility of plasticizers being responsible. I suspect that she overreacts to cytokines or something. She got through the procedure without needing any blood.

I have had physicians tell me that patients can't have transfusion reactions to autologous blood and that hypotension is not a sign of a transfusion reaction (even though there is a type named that). I've seen them order irradiated blood because they think it is less likely to transmit infections. If the patient has been spiking a temp for another reason and they write off this temp which is actually due to TRALI or a hemolytic reaction and keep giving more of the unit, they have done the patient harm. If you can tell whether there is a reaction going on by playing the odds based on the patient's history and condition then why do we ever do the testing? I've never had to let a heavily bleeding patient wait for a transfusion reaction workup. If their life was in danger from bleeding the medical director would override the usual policy if needed. I'm afraid, in my experience, the pathologists are more knowledgeable than the bedside physicians in may cases.

We have a pre-op patient with a history of transfusion reactions to autologous blood twice in 2010. The S/S listed include chills, nausea, drop in BP, fever, urticaria, pruritis, cyanosis of fingertips, some shortness of breath. She says that after a workup with an allergist that they think that she reacts to blood stored in plastic and needs any blood she gets to have been stored in glass instead. Does anyone know anything about transfusion reactions to plasticizers in blood bags or the like? We are pretty sure we could save her life with pre-medicating for any needed transfusion and avoiding transfusion sounds like a great plan but I'm interested if anyone has any information on the topic. Also, is it possible to collect blood for transfusion in an FDA-approved glass bottle in the US?

Another reason why our computers are better at selecting ABO compatible units than serological testing is.

Another caveat about doing titrations on the Vision is that it always runs all 10 (or 12?) dilutions. That will burn through a lot of reagent cells unnecessarily on a titer of 4! I agree with those above that it is critical that the OB/GYNs know that you are using a method that gives different results than their textbooks are based on. Every gel titer result should go out with a comment explaining how its results correlate to the literature for further evaluation of the pregnant person. At least nowadays they are likely to follow with Doppler ultrasounds rather than riskier, invasive amniocentesis. I think a review of the CAP survey results is very enlightening.