Mabel Adams

I think Texas is studying this. I have heard that the cold-stored platelets are already activated so are thought to work well for rapidly bleeding patients. I don't think activated platelets last well in your average oncology patient.

IS XM in Ortho gel uses the neutral card, while IAT XM requires the IgG card. We don't currently stock the neutral gel cards. Our small hospitals are gel-only so any IS XMs needed there are done by using the neutral wells in the ABD/Reverse card that were intended for the reverse type. They do these maybe once a year at most.

We have for IgG XM but not IS. The latter is very fast in tube and we don't do it except during computer downtimes and some rare occasions. We use the electronic XM for most.

We have had several openings for many months. One problem in this tourist town is that no one can afford to move here. We have 3 travelers in the lab in our hospital and several more in our smaller hospitals. One tiny rural hospital in our region has zero lab employees--only some travelers and a respiratory therapist trying to supervise the lab. We have been sponsoring lab assistants and other current lab employees to take online MLS programs for a few years so we grow our own, but we don't have the bandwidth to do the clinicals for more than a few per year and that won't fill all of our positions. The next few years will be rough as the college students who may have taken a pause going to or through college in the past two years will slow the pipeline of outcoming new grads. And this is a smaller generation than any before. I suppose the peak of boomer retirements may have happened already but there are still some of us left.

In other lab testing, we would not expect the reference lab to do additional tests and charge for them beyond what is ordered. I understand the need when doing an antibody workup as these things are interrelated. Why would a reference lab need the ABO/Rh of the father of a baby of a pregnant woman with anti-Kpa? I know that they should do a DAT before using IAT antisera, but to me that is QC, and need not be a reportable test, nor charged for in this case. Molecular would be more expensive than typing for Kpa/Kpb antigens serologically and cost is a barrier to getting the testing done. I have tried in the past so I doubt that I can have any impact whatsoever on the policies of our reference lab but I was wondering if I might find somewhere else to send these antigen type specimens that will do only the testing we order.

Dr. Blumberg, I have long been impressed with your amazing knowledge. I keep some of what I have learned from you in my head even though the mainstream has never accepted it. Thanks for sharing so much all of these years. If we were to use liquid plasma, it would be group A and have an expiration of 26 days from collection (5 days beyond the whole blood it started as). It would be in our small hospitals because they lack time to thaw plasma when a trauma lands at their door. The flight services that serve our area are carrying liquid plasma now along with O neg red cells. As the cost and availability of O red cells has become more of a problem, we are looking for ways to start out our trauma or MTP patients with plasma instead of red cells. The trauma surgeons like the idea of having some clotting factors given first (although liquid plasma on day 26 will have low levels of several labile factors). We would plan to never give more than 2 units of liquid plasma to a given patient. We are a smallish, remote, level 2 trauma center. We currently keep 2 units of thawed, group A, 5 day plasma at our main hospital for traumas/MTPs. Our small hospitals would use it so rarely that 5 day plasma would go to waste too often. We also have MTPs that don't turn out to be massive. The patient gets maybe 3 units of uncrossmatched red cells and then they realize they weren't that bad after all. If we start with 2 units of plasma, they may not even use any red cells. Are you thawing plasma and keeping it for more than 5 days as "liquid plasma"? Another question: irradiating liquid plasma won't necessarily mitigate the WBC issues that you describe, will it? The lymphocytes can't multiply but the WBC antigens, biologic mediators etc. would still be present to wreak the havoc you described, wouldn't they (depending somewhat on leukoreduction, of course)? Sorry to ramble so.

Do those in the US who use non-ARC IRLs get charged for ABO & Rh on every specimen sent, even if all that is ordered is a non-ABO/Rh antigen type? Also, if you order a k type on a patient (say, you have already done the K type but need to see if this father is homozygous for K) does your reference lab test (and charge) for both K and k regardless of how you order it? Lastly, if the order is for, say, Kpa testing (where the antisera requires IAT testing), does the IRL charge you for a DAT on the patient? We are having a hard time passing on these charges for tests that weren't ordered by the provider.

We are ready to consider discontinuing the BB armband. Phlebotomy has worked hard to reduce the number of 'scan overrides' in Epic when collecting our specimens. We still have some work to do on Nurse Collects. That is an important milestone for me. The transfusion side (BPAM) does a good job of accurate ID but I want the specimen collection to be equally accurate before I switch. We still have concerns about pre-op patients who aren't wearing any Epic band to scan when their pre-admit specimen is drawn. (I'm taking advice on how others manage these.) Likewise for outpatient transfusions. As of now, we have a blank line on the Epic blood release form that the nurses record the BB band # on before they bring or send it down to blood bank. We have those forms print on the nursing unit. The BB band # is not documented in Epic, but we have a custom flowsheet row where they acknowledge that it was checked and matches.

If you test in gel, I find that many warm auto antibodies seem to react better with D positive cells in gel.

Can anyone explain the justification for irradiating liquid plasma (never frozen) used for trauma patients when we don't irradiate the red cell units they get? I know the RBCs are leukoreduced so don't contain many viable lymphocytes but there were cases of GVHD if LR units weren't irradiated. Our liquid plasma is made using a hard spin so I would think that there aren't many WBCs in it but no one seems to be able to tell me how the number of lymphocytes in liquid plasma compares to the number in a LR red cell unit. Maybe this is because the big places irradiating their plasma have their own irradiators. For us, it would nearly double the price of the plasma unit so I need justification.

Does anyone know an estimate of the number of viable lymphocytes in liquid plasma compared to red cell units? Our liquid plasma would have been made from a hard spin, I think, as ARC does not make whole blood platelets. I think that should mean that most of the WBCs go with the red cell unit and then most are removed by leukoreduction. We don't give our trauma patients irradiated red cells; do liquid plasma units have some order of magnitude more lymphocytes then leukoreduced red cell units that would require irradiating the plasma but not the red cells?

This process coats the vial #4 cells with a monoclonal antibody, not human source anti-D so, to us, it seems like just making it look like you did QC rather than really testing anything besides the camera and algorithm. I agree with Joanne that you have proved with the screen QC that the IgG gel cards work, the camera can read and the computer can interpret. If it didn't make the DAT cell suspension properly, the algorithm would flag that. We continue to jump through this hoop because our TJC inspectors probably will expect it and Ortho told us to do it initially.

We had a melanoma patient on Nivolumab = Opdivo who apparently has hemolytic anemia but his IgG was only microscopically positive and his complement was negative. Hgb 5.5. Retic % slightly elevated, absolute retic normal, immature fraction retic very high. Bili and LDH normal. Hpt <14 and responded to steroids. They blamed this drug so I hunted up this article. This was new to me so I wanted to share it. Clinical Trial Am J Hematol 2019 May;94(5):563-574. doi: 10.1002/ajh.25448. Epub 2019 Mar 13. Clinical and laboratory features of autoimmune hemolytic anemia associated with immune checkpoint inhibitors Rebecca Karp Leaf 1, Christopher Ferreri 2, Deepa Rangachari 3, James Mier 3, Wesley Witteles 4, George Ansstas 5, Theodora Anagnostou 6, Leyre Zubiri 1, Zofia Piotrowska 1, Thein H Oo 7, David Iberri 8, Mark Yarchoan 9, April K S Salama 10, Douglas B Johnson 11, Andrew D Leavitt 12, Osama E Rahma 13, Kerry L Reynolds 1, David E Leaf 14 PMID: 30790338 DOI: 10.1002/ajh.25448 Free article Abstract Immune checkpoint inhibitors (ICPis) are a novel class of immunotherapeutic agents that have revolutionized the treatment of cancer; however, these drugs can also cause a unique spectrum of autoimmune toxicity. Autoimmune hemolytic anemia (AIHA) is a rare, but often severe, complication of ICPis. We identified 14 patients from nine institutions across the United States who developed ICPi-AIHA. The median interval from ICPi initiation to development of AIHA was 55 days (interquartile range [IQR], 22-110 days). Results from the direct antiglobulin test (DAT) were available for 13 of 14 patients: 8 patients (62%) had a positive DAT and 5 (38%) had a negative DAT. The median pretreatment and nadir hemoglobin concentrations were 11.8 g/dL (IQR, 10.2-12.9 g/dL) and 6.3 g/dL (IQR, 6.1-8.0 g/dL), respectively. Four patients (29%) had a preexisting lymphoproliferative disorder, and two (14%) had a positive DAT prior to initiation of ICPi therapy. All patients were treated with glucocorticoids, with three requiring additional immunosuppressive therapy. Complete and partial recoveries of hemoglobin were achieved in 12 (86%) and 2 (14%) patients, respectively. Seven patients (50%) were re-challenged with ICPis, and one (14%) developed recurrent AIHA. Clinical and laboratory features of ICPi-AIHA were similar in DAT positive and negative patients. ICPi-AIHA shares many clinical features with primary AIHA; however, a unique aspect of ICPi-AIHA is a high incidence of DAT negativity. Glucocorticoids are an effective first-line treatment in the majority of patients with ICPi-AIHA, and most patients who are re-challenged with an ICPi do not appear to develop recurrence of AIHA.

Can anyone give my a ballpark price on purchase of an X-ray irradiator? Probably not the Raycell unless their parts and service TAT have improved and they have a smaller footprint. I need an idea if it is $50 or more like $500K. Thanks.

Also, why do all of the methods I can find still include the 37C reading? AABB Tech Manual, John Judd's book, Harmening, Blaney & Howard all reflect this (some may be older editions). Even Immucor's instructions for their screen cells include it. Quotient/Alba screen cell instructions list it as optional.

So why did we read tube screens at 37C in the old days. I vaguely remember reports of anti-E that reacted only at 37 and not at AHG. I am wondering if that was back when the enhancement was albumin.

What have you all decided will have the most impact on your usage of O red cells as we must dial this back significantly, it appears.

Thanks for the heads up. Our meeting is at noon. Oh my!

Our Red Cross says there will be an announcement tomorrow and that our rep will be available to "answer our questions". Does anyone know any rumors whether it is a national thing our just our region?

Does anyone know of a list of what's changed between the old AABB quality system and the new PROPOSED Quality Systems Framework? I don't have the old requirements memorized to know what is new in the proposed version. Or are they just wordsmithing with no substantive changes? Thanks hive mind.

ABO antigens are present on many other tissues besides red cells. I wonder if they serve additional functions in some of those tissues.

We use the Safe-T-Vues but people have to learn that they are not out of temp until the whole circle is completely red. They also have to learn not to handle them too much when applying them, especially the hot-handed people. How are you meeting the requirement for alarms on your coolers? If you are recording the temperatures at least every 4 hours, I guess that might get you by. I consider holding blood for days in a cooler to be storage not transport so alarms are required (or Q 4 hour temperatures).

When our air ambulances give blood, it is wrapped into the charges for their service. I don't believe they charge by line-items. We bill the flight service for any units used. I don't know how it would work with a ground ambulance. We have contracts with the flight services that covers this. If they use the blood we supply to them to fly a patient from a scene to a different hospital, they tell us who the patient is (Name, DOB at least) and we enter them into our BBIS (SafeTrace Tx) even if they have never been registered in our HIS. We have a protocol to assign them a fake MRN to keep STTx happy. This might not work with Meditech because the BB module doesn't have separate patient registration capabilities as I recall. If the patient has a record in our HIS, we use their established MRN but create a visit in STTx. We manage final disposition for all of their units. It is in the contract that any recall will be sent to them for follow-up with recipient. This has never been needed.

Thanks for this. It took me a bit to realize that I could choose 2 shifts by holding the Ctrl key. The wages only allow one value, but I was able to put the wage range in the body of the description so it worked.

We state that they should start the transfusion within 30 minutes, but that is not a "must", just a recommendation of good practice. If they ask us, we will say that the blood should be infused within 4 hours of issue, but they probably use 4 hours of start of infusion sometimes. I think this falls under the practice of medicine, although it might matter what the SOP says you are to do.