Mabel Adams

Just to give credit where credit is due. “Obtaining compatible blood for a corpse is not a therapeutic triumph.” Ed Snyder, MD (Yale University) ISBTS meeting (Edinburgh) September 6, 2002

She came back as a weak D type 1. Her second specimen (the one we sent out) typed similarly to the first in tube--neg at IS and 37C but pos at AHG.

There's a recipe for this in the AABB publication, Blood Banker Favorites: A Collection of the Best Recipes for Blood Sample Preparation.

Many small hospitals lack the ability to reprint ISBT labels and create barcoded expiration dates, so it is acceptable to manually change the expiration dates on plasma to an expiration date of 24 hours. You must mark out the license number. Also make sure your nurses can't scan the original expiration barcode into the EMR by thoroughly marking through it or similar means.

Doesn't Ortho sell the liquid sera for antigen typing in gel? Or do they not include the Rh types?

Yes, that is valuable for the treatment advice. For the transfusion decisions, my plan is to say, "don't unless necessary", then, if there are enough compatible units and Ab titer is very high, start with a couple of compatible units. Once antibody has been bled out, then use random units and, if you can guess when the last few units will be given, make them the more compatible ones to reduce the RBC destruction in the coming days. If titer is lower or there are few to no compatible units, start with random units and try to fill the patient up with the (more?) compatible units at the end. Maybe with sufficient immune suppression as your article suggests, we wouldn't have to try to guess when the last few units will be transfused. We could keep the compatible ones for single unit transfusions over the ensuing days.

Years ago, I had a short blurb (maybe from Lab Medicine?) on how to transfuse patients with incompatible blood as safely as possible. It included the example of liver transplants and talked of "saving the best wine for last". Does anyone have a reference that covers how to transfuse (of course avoiding it unless life-saving) in the presence of multiple antibodies or antibodies to high frequency antigens? We have a patient with anti-S and anti-Dib. I have some plans for if a life-threatening emergency arose but would like to have a reference.

Did you know that in the UK they would be appalled that we might give K+ blood to a female with childbearing potential in the US because we don't routinely K type either the units or the patient? D isn't the only immunogen out there (although it is certainly very immunogenic, and the number of positive donors outnumber the number of K pos donors). Still, there are other risks than making anti-D that some are equally concerned about.

I'll add that this policy is in keeping with the guidelines of the AABB and Red Cross. If, in the US, we used O neg instead of O pos, we certainly would not have enough O neg left for known Rh neg patients or those with anti-D. We are on allotment for O neg and can't get more than our quota without the supplier's medical director approving a medical release. No change in sight. We can't trade the certain harm to those patients for the potential harm for the trauma patients who are 85% likely to be Rh pos, usually male, unlikely to make anti-D, and usually not likely to require emergency transfusion more than once in their lives. I'll admit that I am having some of the same qualms with the new policies to use O pos whole blood for traumas of any age and gender. Their arguments about the modern treatment of HDFN are probably right, but they are harder to accept for me. We had to start keeping O pos on our helicopters last year because we couldn't manage the O neg rotations anymore. Same risk as the whole blood argument. The only young female transported got the unit of liquid plasma and not O pos red cells.

It's pretty likely it's her blood because baby has a weak D Rh type but, yes, we thought of that.

I am aware of this for the Alba anti-D but never had the reference, so thanks for that. That reagent, with its potentiators, definitely will pick up i on cord cells and, we suspect, the occasional i adult. It is worse if it is cold. It disappears at 37C so is pretty obviously not D. We use it because it has a similar sensitivity for weak D to Ortho gel (usually!!!).

We have an OB patient in to deliver who typed in gel anti-D as a solid 2+. Control is neg. We have typed her 3 times before in recent years using the same methods and she has always tested D negative. Most recent A Neg type was last November. Now with Albaclone anti-D, she is negative at IS and 37 but 1+ at AHG. Her prior baby was Rh neg so no attempted fetal screen test then. This baby is 1+ at IS with the Albaclone anti-D and 3+ at 37C and AHG. We don't usually run cord blood Rh types in gel. We will recommend the patient be sent for molecular testing. My question is what would make her D antigen strength change so much (or make Ortho's gel cards change their sensitivity that much)? I know leukemia can weaken D antigens, but she seems perfectly healthy. No bone marrow transplants. No recent transfusions. No reason to believe she isn't the same patient as before. I can't find any references besides Issitt mentioning changes in D reaction strength. Issitt mostly mentions the Leukemia aspect, but I feel like I have heard of other situations. She had shingles in April and was treated with ACYLOVIR for what that's worth. We are treating her as Rh negative for now.

We are a remote 280+ bed level 2 trauma center. After reading about many mass casualty incidents not being able to get all the patients registered before they need transfusion, I created a process and form for taking a box of blood to ED and handing it out while recording some way to know which patient got it. Not sure it will work. Would depend on a supervisor or someone available to do this as everyone in the BB will be super busy already. I had to come to the conclusion that a Las Vegas level shooting here would exceed our blood supply capacity and some patients just wouldn't be able to get transfused. Hard reality of being rural. For more manageable events, we would use our MTP and emergency release processes as best we could. One challenge would be knowing where patients were being sent in our system of 3 critical access and one bigger hospital which are all 20-60 miles apart. The big one is not in the center of the others. We have started sending a cooler of 2 units of plasma to our "full trauma" activations (over about age 5). If they are really bad and become MTPs, they need the plasma. If it gets wasted it is not as dire as wasting O pos or O neg RBCs. This requires no decisions on which Rh type to give for males and females. We keep 2 A plasma thawed at all times for this.

We give O pos for all uncrossmatched blood orders for males and females over 50. We've done it for a couple of decades. We avoid it if the recipient is known to have anti-D already. We have seen very few make anti-D.

Ortho is sending us a free sample of their new QC kit, and it includes CcEc antigens appropriate to QC. Are you using the Rh CcEe gel cards or the additive reagent of Ortho's? I'm interested in whether we could use the tube anti-c on the Vision with neutral gel cards (or why we shouldn't).

Does anyone include haptoglobin tests in their transfusion reaction workup (probably just the extended workup when hemolytic reaction is expected)?

AABB Director of Regulatory Affairs answered my post on the AABB page saying that PR platelets in the US can't be 7 days and they will review the article.

We are considering CSPs but we are 4 hours from our supplier and can't predict whether use that day will be prophylactic or bleeding patients. Also, our ARC won't make CSP platelets for the near future so they will have to come Fed Ex with 10 days left on them. We are trying to gather data on our usage pattern for types of patients, but it is extremely variable week to week. If anyone has a reasonable way to model this, please share! ARC requires a standing order so we couldn't get more CSP if we used them until the next shipment.

We keep single cryo units for neonates. We thaw it and pull it into a filter syringe, so it is filtered when we issue it like everything else that we issue to NICU. We have been negotiating the proper dosage after an order for 15 ml/kg on a term newborn seemed excessive and required 2 single cryo units. We came upon a guide from Children's of Minnesota that our neonatologists like. Cryoprecipitate Transfusion Dosing Table (childrensmn.org)

We put two sensors in our big refrigerators but only test alarms on the top one. The bottom one just records the temperature. It would alert us if it got out of range but isn't the one we depend on.

I'm correcting this because I learned that Diluent 2 does have antibiotics, but it lacks some other chemicals used in prediluted cells. This information is from the instructions for use so you can verify what is in each.

Latest issue of AABB News mentions that both LVDS and PR platelets have seven-day shelf-lives but ours from ARC are still 5. Can someone explain how we can get 7-day PR platelets? Is this an ARC problem? We really don't want to start using Verax on LVDS platelets because we hope that more improvements are coming to platelet dating soon. Cold stored can be used only for bleeding patients so we couldn't always use them up, they must be on standing order only, and we are 4 hours' drive from our supplier for getting more RT plts.

AABB published a book called Blood Bank Favorites: A Collection of the Best Recipes for Blood Sample Preparation. It has instructions for about everything you might need to create.

What company's temp monitor do you use for this?

I see TJC standard QSA.05.06.01 now says: Each day the procedure is performed, and when a new lot of reagents is first used, the laboratory tests at least one vial from each lot number of antisera, reactive cells, and reagents for reactivity. The reactivity results are documented. Note: This testing includes positive and negative reactivity when recommended by the manufacturer. We have always thought that JC requires QC on all open vials even if they are the same lot number. Does anyone know when this changed? Or is there a different standard that contradicts it?