[CAP ALL COMMON CHECKLIST COM.04250]

If we have to hunt for a sample to use for this that will give consistently comparable results, we aren't testing the method, we are testing our ability to find a suitable sample.  I heard that CAP will sell you one that will consistently give the same results.  If we aren't going to change anything (can't recalibrate gel!) based on the answers we get (like chemistry would), then why are we doing this?  I talked TJC out of it last inspection (I probably got a little heated over the stupidity of it because I had to come in the day after a concussion to meet with them, but maybe they took pity on me and didn't cite me because of my unfiltered brain).  No one has been able to explain to me any meaningful takeaway from doing this comparison.  If I am ever forced to do it, we will just keep copies of sample results that we run by two methods to solve a problem and make a note that they are acceptable because we expect these differences between methods.  If anyone can give me a valid use for this, I would be very appreciative.

[Anti-C in C pos patient with strong e type]

On 8/7/2023 at 5:09 AM, Malcolm Needs said:

However, if the patient does express one of the rarer Rh types mentioned above, say she is RzRo, she can actually produce an allo-anti-Ce, and most antibody panels only contain C+ red cells that are only Ce+ as well.  In other words, her antibody in the plasma MAY be identified as an anti-C, whereas it is actually a monospecific anti-Ce, which would neatly explain why she has an apparent anti-C.

If this were the case, wouldn't she react with e+ cells as well as C+ cells?  Or does anti-Ce tend to react more strongly with C than with e?

[Anti-C in C pos patient with strong e type]

On 8/7/2023 at 5:09 AM, Malcolm Needs said:

I think it was John C Staley who once accused me of looking for zebras, when I hear horses hooves (I may be wrong, but I think it was John).  Anyway, this proves that he was absolutely correct about me!!!!!!!!!!!!!!!!!!!!!!!!

I've been accused of looking for unicorns when I hear hoofbeats!  

[Blood unit patient label]

We print bag tags on ISBT Q3Q4 label stock which we then put on manila tags and use a plastic tie to attach them to the units.  This way we can use the same printers and label stock for making labels for 5-day plasma.  Our nurses document in Epic or on downtime transfusion records that have space for a duplicate of the bag tag labels.

[Anti-C in C pos patient with strong e type]

I'm over my head with this case for a Friday afternoon.  Patient is a 70 yo apparently Caucasian female who was transfused in 1981 in childbirth.  No transfusion since. She was in ED for a fall but has been discharged.  Very limited sample volume.  O pos.  Appears to have anti-C reacting 1+ in gel.  Reacts 1+ with another cell that is C neg and HLA pos. HLA is noted as present on 2 of the C+ cells that react but not on the other three C+ cells that react.  Have negative reactions that allow ruling out all of the other usual suspects.  DAT is 3+ with IgG; neg for Complement.  Patient types C+, E+, c+, e+ with the e reacting quite a bit more strongly than is typical with our Ortho anti-e reagent (comes up solid 4+ at immediate spin).  We have not done an eluate, partly because it seems not worth the resources because she has been discharged.  I suspect a mimicking anti-C autoantibody or just Bg antibodies, but is there anything else we should be thinking about?  I get confused in all of the rare Rh variants so thought I would save myself a lot of reading and ask the experts. 

[Incompatible Blood]

If we know the patient has anti-E, for us that would justify using O neg for uncrossmatched if it didn't deplete the O neg supply too much and we could screen O pos for E quickly.  More so for known anti-D.  Not saying anything was done wrong in this case. 

[RBCs for babies]

We use Adsol units for small volume transfusions. We remove the plasma/additive for exchange transfusions and replace it with AB plasma. St Charles in Bend OR.  Our NICU is the highest level (3, backward from trauma designations) but not that big.  We have a 24 bed capacity.

[1 or 2-person check for plasma protein product]

If you give the same product to all patients regardless of age, blood type, gender etc. then why an extra check?  Assess the risk for this product being infused improperly and compare that risk to other things that require 2-person check to see if it is anywhere near equivalent.  Probably there was some historical computer system that required it and now it is "how we've always done it".

[Platelet swirl revisited]

We put the unit in the incubator and this morning it shows some swirl, so we are accepting it. 

[Cold stored platelets and a happy BBIS]

On 7/10/2023 at 6:02 AM, Baby Banker said:

Maybe you could make a Product Group for it.  I did that with Octaplas.

Yes, I think that is probably what would be required.

[Platelet swirl revisited]

In this modern world where cold storage of platelets is now accepted by FDA and almost all are pathogen-reduced, what do we do with a room temperature stored platelet that lacks swirl?  Give it to a bleeding patient like cold-stored platelets? Do you reject platelets that arrive from the supplier within appropriate temperature but lacking swirl?  Do you have an assessment that helps you decide they are okay to use?

[Cold stored platelets and a happy BBIS]

Has anyone considered how to build for cold stored platelets in their BBIS?  SafeTraceTx at least, has expected temperature ranges for products on return from issue or delivery so we couldn't very well lump cold stored platelets in with other platelets.  I guess we could build an entirely new product class with its own temperature range.  Not that we are going to get cold-stored platelets anytime soon, much as we would love the 14-day shelf life.  We are too small and remote to keep a dual inventory for oncology vs. trauma patients.  I'm just curious how others plan to solve this issue.  After all, the driving force of our lives is keeping our computers happy, right?  Now if FDA would just approve 7-day expiration for all PR platelets!

[Post-partum workup]

On 6/2/2023 at 9:37 AM, Malcolm Needs said:

The trouble was that, in those days the anti-D immunoglobulin was known as "anti-D for Mum's Bums" in the UK, as the shot was given in the gluteal muscle.  But, there was an awful lot of fat in that muscle, so the anti-D had a habit of "staying there", rather than being adsorbed into the blood stream.  This meant that, even when the dose of anti-D immunoglobulin was calculated from the Kleihauer-Bekte test, the actual dose reaching the circulation was far lower than the calculated dose, and women used to produce allo-anti-D as a result.  Nowadays (at least in the UK) the shot is given in the lateral deltoid muscle, where there is a good deal less fat, and so the shot is adsorbed into the circulation much easier, and so there are fewer cases of maternal allo-anti-D.

I realise that this is a very vague explanation, and that there are many other causes of anti-D immunoglobulin being less than effective (such as giving it to the father, or even to the ambulance staff (SHOULD be unbelievable, but is actually true), but it does show just how complicated such a simple thing as this can be.

Does anyone remember the humorous/terrifying thread on here more than a decade ago of all of the insane things we had heard of?  "I can't hang this plasma on my patient, it's liquid and the doctor ordered FROZEN plasma".  Or, "I don't care if the plasma isn't thawed yet, I need to hang it stat! Send it up now!" "I ordered that blood culture stat and it's been 2 hours.  Why don't I have a result yet?!"

[Prenatal Antibody Titers]

I always based my judgement on the fact that the original studies to determine significant titers were done using double dose cells.  Plus, nowadays, with donor eggs, the baby can be homozygous for the antigen.

[Post-partum workup]

Anyone else remember when the RhIG used to come with some of it in a separate vial which we had to test against the patient's cells? I guess to prove that they really were Rh negative.  We definitely had to do an antibody screen with that.  That was before 28-week RhIG or Fetal Screen/rosette tests.

[Post-partum workup]

There used to be a regulation that the birth parent not be sensitized to D to be a RhIG candidate.  We trust that the baby lacking a positive DAT due to anti-D is sufficient evidence and have not done anything but the needed Fetal Screen in a couple of decades, even when we didn't do admission T&S routinely.  I think key is what will we do differently with the results?  If you detect anti-D, you will assume it is RhIG and give RhIG again.  If the Ab screen is negative, you will give RhIG.  The test doesn't change the treatment so why do it?  This assumes that a strong anti-D, clearly due to sensitization, would cause the baby to have a positive DAT and therefore any needed workup would be completed for that reason.

[Pt reacting to mts diluent]

Most of our antibodies to gel diluent react only with the pre-diluted reagent cells, but not in cells suspended in MTS diluent 2 (auto control, XMs).  There are no antibiotics in the diluent 2 because those suspensions are discarded promptly whereas the reagent cells must remain stable for weeks.   If there are antibiotics in the gel itself, we have not seen reactions to that, but it makes sense.

[Antibody Identification and Patient Antigen typing timeline]

We accept patient (and unit) antigen typing done at our reference lab.  I don't see why this would be different.  You are there reference lab for anything that is beyond their limited ABID scope, right?  

[donor units with alloantibodies- policy for transfusion]

Can anyone share policies regarding transfusing donor units that contain alloantibodies?  We just got a unit in that is labeled as containing anti-M.  We don't usually get in units with antibodies, but I am not very concerned about using this one as long as we avoid giving it to a small child, because most anti-M antibodies aren't very significant.  Am I missing anything? 

Back in the days before Adsol, we used to get units with anti-D sometimes which we made sure went to D negative recipients.  Additive solutions should dilute the plasma somewhat, so there should be less antibody in the unit than in those days.  Then it would get diluted further in the recipient.  Thanks for any modern guidance.

[CPT codes used for PEG crossmatches]

On 4/6/2023 at 7:04 AM, Bet'naSBB said:

Our PEG and LISS testing are built the same - with 3 charges - one per phase of testing.  We do observe for hemolysis with PEG testing after 37 incubation (do not spin) - so, no hemolysis is resulted in our LIS as negative.

We used to document no hemolysis at 37 on PEG testing but with EDTA samples preventing complement activation, that's sort of moot.  I guess maybe recording a result at 37 helps justify the charging for all 3 XM CPT codes.  Or maybe just the fact that we incubate it is enough to charge for that phase.  Our computer doesn't expect a result at 37, only IS, AHG & CC for PEG. The "incubation" CPT code description doesn't say it is read at that phase, I guess.  Maybe I am splitting hairs.

[CPT codes used for PEG crossmatches]

What CPT codes do you charge for a PEG XM assuming you do an IS phase, incubate but don't read at 37, then an AHG/CC phase?  Do you charge for the CPT codes for all 3 phases or only for those phases at which you read the test?

[Sonoclot analyzer for viscoelastic testing functional coagulation assay info]

Does anyone know anything about the Sonoclot platform for viscoelastic testing?  I know about TEG, ROTEM and Quantra but someone mentioned Sonoclot also.  I will also take feedback on the Quantra system if anyone has any to offer.

[Workstation Recommendations]

11 hours ago, exlimey said:

Any of the major laboratory suppliers can help with lab design and furniture, for a price, of course. VWR (Avantor) and Thermo-Fisher are probably top of the list. I think that Mabel is referring to "Herman Miller" - a longtime standard for labs and offices. I think they may sell direct or through the distributors.

Good luck. Designing a new space can be both fun and frustrating. Nothing can ever be perfect, compromises always have to be made.

Yes!  Herman Miller!  They are modular so can be reconfigured rather than requiring remodeling for analyzer changes etc.

[PEDIATRIC MASSIVE TRANSFUSION PROTOCOL]

I tried hard a few years ago to find evidence for this but found nearly nothing in terms of evidence-based guidelines.  I will try to add here what I came up with, but it is fairly arbitrary.  It is part of our MTP document.  It loses a lot of formatting here.  Sorry.  Broselow Tape is used in ED to estimate the size of a child.  Maybe see if your ED can share what this looks like.  This information is intended to be of practical use as a loose guideline for the poor blood banker working on the unusual day that we get a pediatric hemorrhage in.  I am very open to improvements.   Good luck!

Broselow Tape Patient Size Correlation:

	Grey 3-5 kg	Pink 6-7 kg	Red 8-9 kg	Purple 10-11 kg	Yellow 12-14 kg	White 15-18 kg	Blue 19-23 kg	Orange 24-29 kg	Green 30-36 kg
Wt. in Lbs.	7-11	13-15	18-20	22-24	26-31	33-40	42-51	53-64	66-79
Approx age	< 3 mo.	3-9 mo.	4-15 mo.	1-2 yr.	2-3 yr.	4-5 yr.	6-7 yr.	8-9 yr.	10-11 yr.

 1 unit Platelet order at SCHS = 1 apheresis platelet = 6 units of whole-blood-derived platelet (6 pack)

• Product = any and all types of blood component therapy, to include RBC, plasma, platelets, and cryoprecipitate.
• Bend only: Group A plasma may be used as universal donor plasma for adults and children over about age 5.

Blood Products	Grey 3-5 kg	Pink 6-7 kg	Red 8-9 kg	Purple 10-11 kg	Yellow 12-14 kg	White 15-18 kg	Blue 19-23 kg	Orange 24-29 kg	Green 30-36 kg	Adult
MTP Round 1	10 ml/kg is ~equivalent to 1 unit RBCs to an adult.
Red Cells	1 unit *	1 unit *	1 unit	1 units	1 units	2 units	3 units	3 units	4 units	4 units
Plasma	1 unit †	1 unit †	1 unit †	1 unit †	1 unit †	2 units †	2 units	2 units	2 units	2 units
Platelets	‡	‡	‡	‡	‡
Cryoprecipitate	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100
MTP Round 2	Repeat Round 1	Repeat Round 1	Repeat Round 1	Repeat Round 1	Repeat Round 1
Red Cells	1 unit *	1 unit *	1 unit *	1 units	1 units	2 units	3 units	3 units	4 units	4 units
Plasma	1 unit †	1 unit †	1 unit †	1 unit †	1 unit †	2 units †	3 units	3 units	4 units	4 units
Platelets	‡	‡	‡	‡	‡	1	1	1	1	1
Cryoprecipitate	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 single cryo as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100
MTP Round 3	Repeat Round 1	Repeat Round 1	Repeat Round 1	Repeat Round 1	Repeat Round 1
Red Cells						2 units	3 units	3 units	4 units	4 units
Plasma						2 units †	3 units	3 units	4 units	4 units
Platelets
Cryoprecipitate						1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100	1 pool of 5 as ordered or if Fib <100
Continuing Rounds						Repeat Rounds 2 & 3	Repeat Rounds 2 & 3	Repeat Rounds 2 & 3	Repeat Rounds 2 & 3	Repeat Rounds 2 & 3

* If < 4 months old (grey & pink)

·         Irradiated blood & platelets not required unless specifically ordered by physician.

·         Continue to give only O RBCs & AB plasma regardless of baby’s blood type.

·         Unless AB platelets are available or they request otherwise, wait to give ABO-incompatible platelets until the baby has had a partial transfusion of O RBCs to reduce ABO incompatibility.  Avoid giving O platelets on a non-O baby.

·         Syringes with filters issued with RBCs and platelets in case preferred over blood administration set.

·         Still must use blood warmer for massive transfusion if syringes used.

·         All blood products must be filtered, either by blood administration set or syringe with filter.

† Thaw AB plasma as universal donor on all peds under ~18 kg (40 lbs.—around age 5). Don’t use A plasma for them as universal donor without physician/pathologist approval.

‡ Issue platelets with instructions to give only part of the unit or run it as needed over 4 hours (or can aliquot if time).  These are the fractions of a unit proportional to the RBCs being given in each round. Communicate this information to nurse.

Grey 3-5 kg	Pink 6-7 kg	Red 8-9 kg	Purple 10-11 kg	Yellow 12-14 kg
1/5	1/5	1/3	1/3	1

This policy does not apply to exchange transfusions of neonates.

 

 

[Nursing verifications done at bedside before transfusion]

Oh my!!!  We used to have a flowsheet row in the Epic transfusion module that the nurses were to mark that they checked the blood bank band number and it matched (then we dropped using a BB band).  It wasn't a required field, but I suppose you could make it so.  How is Lab supposed to police the work of nurses who are overworked, short staffed, often travelers and over whom we have zero power to change their behavior!