Mabel Adams

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.

Does anyone know if Hydroxocobalamin (Cyanokit®) interferes with blood bank testing, particularly MTS gel? We had a house fire smoke inhalation victim be given this and his plasma is really dark red. I see online that "Due to the deep red color of hydroxocobalamin, it can interfere with colorimetric methods used in laboratory measurements such as aspartate aminotransferase, total bilirubin, creatinine, magnesium, and serum iron. It also may interfere with co-oximeter testing of carboxyhemoglobin, methemoglobin and oxyhemoglobin." http://www.mdpoison.com/media/SOP/mdpoisoncom/healthcareprofessionals/antidote-facts/hydroxocobalamin antidote facts.pdf We were wondering if it would interfere at all with blood bank testing (besides the obvious difficulty in being able to read the reaction through the color of the plasma in tube testing). [Sorry about the text boxes below that I can't figure out how to delete.]

Daniels says, "Of those anti-Yta sera that could be subclassed, most contained IgG1, some IgG1 plus IgG4, and a few IgG4 alone; none contained IgG3. Some anti-Yta bind complement, others do not." He also includes results of testing fetal antigen strength (< 32 weeks gestation) and found 8 of 10 did not react with anti-Yta but 2 did, albeit very weakly. Interesting stuff. Thanks so much for sharing your experience with these.

Since this antibody doesn't cause HDFN due to the antigen not being well-developed in the fetus, why should a miscarriage have sensitized her? Are they ever naturally occurring? If so, does that correlate to significance?

If she requires transfusion, should we make an effort to match her for K, C, E, Jkb etc.? Can we assume that she is a "responder"? If she makes another antibody it will be very hard to figure out what she has quickly (and locally) in the presence of that anti-Yta. She's young. Matching K, C & E would be easy, the Jkb a bit less so, especially among Rh neg units. Is the anti-Yta likely to remain detectable for decades?

We have recently identified (with reference lab confirmation) an anti-Yta in an A neg pregnant woman. She has had one prior pregnancy--miscarriage-- and no transfusions. We are 3.5 hours from our blood supplier (over a mountain pass) in good weather and she is due about Christmas. We are convinced that the risk of HDFN is nil so I am devising a plan for managing the patient if she should bleed during delivery. We can have the MMA done for significance but it is expensive and maybe not worth it when the patient isn't all that likely to bleed excessively. I am about ready to decide that we should just wing it because I can't get in compatible units "just in case" because they probably would have to be deglycerolized and thus would have a 24 hr expiration. If she massively hemorrhages, I won't have any choice but to give her Yta untested units. If she doesn't have a life-threatening bleed there might be time to get in Yta negative blood in a day or 2 to fill her back up. Autologous donation would give us only maybe 1 liquid unit and they probably would want to transfuse it even if she didn't need it. Not sure if there is a family member but they can only donate every 56 days and I would want a liquid unit for the month around her due date. Maybe a sibling could donate a double red cell but that's about the best it will get (assuming there is a Yta neg sibling). We would try to send out an antibody workup in the last 2 weeks before her due date just to make sure there aren't any new antibodies that we will want to honor. Of course she will have RhIG on board by then I'm sure. I will happily take all suggestions and input.

We use an armband system on our NICU babies although they are allowed to keep the band on the isolette (do they still call them that?) so it may be more for consistency's sake than the usual function of the BB band. Because of that we wouldn't use a sample from Hem or Chem. We give only O neg in NICU (unless it would be incompatible with mom's Abs which hasn't happened yet). We have not had a NICU baby need transfusion after 4 months of age so far. If it happened, we would have to go to drawing a new specimen on baby every 3 days. We keep the same band on patients for their whole stay so that # would be checked and recorded on specimen at each redraw but the band not replaced.

Or maybe this works: Peter D. Issitt, F.I.M.L.S., M.I.Biol., M.R.C.Path., (Reprints), Director of Laboratories and Associate Professor in Research Surgery; Beverly G. Pavone, MT(ASCP)SBB, Assistant Supervisor of Education, and Research Technologist; Judy A. Tessel, MT(ASCP)SBB, Supervisor, Reference Laboratory, and Maureen A. Carlin, MT(ASCP), Graduate Student; The Paul I. Hoxworth Blood Center of the University of Cincinnati, 3231 Burnet Avenue, Cincinnati, OH 45267

See my private message with contact information from AABB for Marilyn Moulds. She might have known Ms. Tessel.

Thanks, Scott. I was thinking that might be the best option.

Is anyone using hospital wristbands with RFID chips in them, at least for OR? If so, what EMR are you on?

It's hard to find clear direction, but I think that our OR should be labeling our autologous skull flaps as "For Autologous Use Only" and "Not tested for infectious diseases" (or some similar wording). Have any of you been able to get your surgery staff to apply such labels? Do you have labels for this that stay stuck at -70C? If anyone has an easy way to do this (special bags, labels etc.) I'd love to know about it.

If you use Ortho gel for your IAT XMs they say that you must also do some other method to detect ABO incompatibility as their gel can't be relied upon to detect it. So you can't skirt the incompatibility by doing just an IAT XM (unless you have an alternate approach to determining the ABO compatibility of the unit that is unaffected by the anti-A1). Our computer system would get all antsy about us giving A units unless they were specifically A2. We just give O to keep the computer happy and make life easier. Dr. Blumberg has been trying for years to get people to pay attention to the risks immune complexes. Maybe I should read that paper.

The patient gets O until we get a second type. If necessary, we can have a pathologist override and let us go to type specific on one specimen. That would most likely be A or B neg female so we don't use up all of our O neg. I think we maybe did that once in 3 years. They are supposed to be drawing coags and/or iStats on our massives every half hour or so anyway so it is isn't like they aren't drawing more specimens. It gets interesting when the redraw is after unxm O pos was given to a patient who is Rh neg because the second type will be Rh pos. We have a policy for keeping the computer happy in these cases.

Terri, what do you do about patients drawn for pre-op or outpatient surgery who aren't wearing hospital bands to be scanned? Also, does Epic ever have downtimes where you lack all of the scanning abilities for a time?

Does anyone use a provider signature form for transfusions with increased risks that are not for just uncrossmatched blood? I would love any examples anyone might share of forms used to inform the provider (and get their signature) of things like incompatible units being issued (warm autos, DARA interference, no compatible units for antibody to high incidence antigen or a HTLA-like antibody, maybe even a compromised specimen that a provider insists must be used for testing or some such). I'd appreciate any examples, explanations or procedures.

If I'd remembered which one, I would have posted it.

I've heard that they can decide it is some weird Lutheran antibody if they don't know it is DARA.

We had TJC tell us that the transfusion start time is when the blood reaches the patient's vein so we use 4 hours after that. That start time is more pertinent to calculating how long the nurse must stay with the patient at the beginning of the transfusion. If the blood takes 8 minutes to reach the vein after spiking then the nurse may only stay with the patient for the first 7 minutes of donor exposure which probably isn't long enough.

We have gone to requiring a blood type once per visit for platelets and plasma due to the ID swaps by patients or by admitting selecting the wrong record (I've seen that a few times as Dragonlady describes). I don't think it is so critical for platelets because we often have to transfuse plasma-incompatible platelets but we wanted to be consistent. This has worked well because our computer system has allowed our OP transfusion patients to continue with the same series visit number for many months meaning we don't retype them for platelets. We will soon have Epic and they will get a new visit # monthly so we will have to change plans. I think we will just allow OP transfusions (of platelets only) to rely on a historical type regardless of the visit number. Everyone else gets one type per admission for the yellow stuff.