Mabel Adams

http://www.nlm.nih.gov/medlineplus/ency/article/000579.htm Try the above link for a simple start. You might find Medlineplus.gov a good place to start with many medical questions. It is a collection of reputable medical sites in the US compiled by the National Library of Medicine. It is intended for non-medical people to learn about health conditions from trustworthy sites. By clicking on "Other Resources", then "Medline/Pubmed" you can search a database of medical journals and at least get references and often abstracts. Sometimes you can read the whole article. Maybe the following reference will refer to the older therapy as well as the new drug being discussed. Otherwise, any textbook on clinical hematology should have some reference to it. 1: Am J Hematol. 2005 Feb;78(2):123-6. Links Two cases of refractory warm autoimmune hemolytic anemia treated with rituximab. Ramanathan S, Koutts J, Hertzberg MS. Department of Haematology, Westmead Hospital, Westmead, NSW 2145, Australia. Autoimmune hemolytic anemia is thought to be mediated via auto-antibodies produced by lymphoid B cells. This may be an idiopathic process or secondary to an underlying infection or lymphoproliferative disorder. Conventional treatment comprises immunosuppression with corticosteroids and, in some cases, splenectomy. A proportion of patients require lifelong immunosuppression to maintain disease remission. Monoclonal antibody rituximab has gained widespread acceptance in the management of B-cell malignancies. Additionally, it has been used to treat disorders associated with auto-antibody production, such as cold hemagglutinin disease, immune thrombocytopenia, and Evans syndrome. Its use in the treatment of patients with autoimmune hemolytic anemia in the setting of allogeneic bone marrow transplantation as well as in patients with an underlying lymphoproliferative disease has also been reported. We report herein the successful use of rituximab in the treatment of two patients with idiopathic refractory warm autoimmune hemolytic anemia, who are still in remission at 15 and 9 months following treatment. Copyright 2005 Wiley-Liss,Inc. PMID: 15682420 [PubMed - indexed for MEDLINE]

In case it isn't clear from this discussion, an in vivo crossmatch is as described above where a small amount of the unit is transfused and the patient observed for signs of reaction. Drawing a sample from the patient before continuing the transfusion and spinning it down to look for hemolysis could rule out overt intravascular hemolysis, but not all incompatibility--especially when dealing with an autoantibody. Treatment of autoantibodies in this country (USA) is usually with steriod drugs to reduce the production of the autoantibody and the destruction of the patient's own red cells. I have seen a patient with a 4 g/dl hemoglobin recover nicely without transfusion. She had a reticulocyte count of about 13 (~10 times normal) so as soon as destruction of her red cells slowed, she made enough red cells to bring her hemoglobin up to 7 or 8 in just a few days. I think most other countries report hemoglobins in other units so the number is 10 times what I listed above.

Can you just post the flow-chart and policy here as an attachment to save yourself all that emailing?

Not only do you have patient ID issues and the accompanying training and competency of any staff that might use the blood products, don't forget transfusion reaction training and competency. Tough to keep up when each surgical staff person might be involved in one transfusion a month or less. Then there is cooler validation and proper use--I'd be putting Safe-T-Vue or Hemotemp stickers on the units. If you put in a fridge there will be alarm tests, daily temps, response to alarms, maintenance, chart changes etc. etc.

Interesting that the anti-Fya would be in the eluate when there shouldn't have been any Fya antigens in the patient for the antibody to attach to. . .non-specific adherence of antibody to Fya neg cells??

One thing I heard was that some of the data coming out of Iraq may not be applicable to the mechanisms of injury of our non-combat traumas. In the war, the extent of tissue damage is much higher than in your average ruptured spleen from a motorcycle handlebar or horse kick. I think it is wise to move in that direction (swifter provision of plts and FFP) but I wonder if the trend suggesting 1:1 will be found not to apply to all massive bleeds once all the hype settles.

Does anyone else require 3 A2, 3 A1 & 3 O cells be tested against the sample of a patient suspected of having anti-A1? Since both Immucor and Ortho's A1 & A2 cells are pools, isn't running just one of each of them sufficient since if there were any other antibody causing the reaction it should give a mixed field result or react with the O cells. (Of course the O cells should be positive for M & P1 to catch those specificities.)

In the world of liver transplants I have heard that they "save the best wine for last" for patients with multiple antibodies for whom it is impossible to get sufficient quantity of antigen negative blood. Some of the text books even suggest giving the first couple of units as antigen negative, then a bunch of unmatched or partially matched units and try to fill them up at the end with compatible blood. Sometimes it is hard to get the info on when they are 6-10 units from the end. There was a write-up on a CAP survey that I had around for years lining out this approach. Honor the ABO and maybe any Kidd antibodies, but otherwise it said that even incompatible blood carries oxygen.

Isn't this a fun one? I prefer to keep the patient labeled Rh neg (even though we have to do the weak D test to verify it is really the same patient/donor) and give allogeneic units as Rh neg. Then I would leave the auto unit Rh pos and just override the warnings and document thoroughly. That said, the lab I just left has Meditech and it won't let you log in an auto unit if the type conflicts with the patient history. So, I tried changing the patient type to match, logging in the unit and changing the patient back. Guess what. Meditech changed the donor unit's type when I changed the patient. It left some sort of a trail that the unit had been in as Rh pos in the past. I have only been gone since July, but I have actually forgotten what exactly I did as a workaround. Just test thoroughly so you know what your system does. Who would have thought that the software would have changed the donor type??!

We are going to the Electonic xm. What do the rest of you do about anti-A1. I know it isn't really considered clinically significant, but with serological xm it sort of took care of itself--A1 units would be incompatible so we would usually do O units. With E-xm if anti-A1 is not put in the computer as clinically significant, I think it would allow A units to be E-crossmatched. Would this be okay or should we make ianti-A1 clinically significant in the computer and require AG xms just for the check for serological compatibility? We could make it a policy to use O units, but the computer wouldn't make sure it happened unless we required full xm.

We used to shake our tubes off by holding them up to the overhead light, then scope everything--agglutination viewer optional. Probably 15-20 years ago, we started requiring use of the agglutination viewer and strongly discouraging routine use of the scope. I had found that I could see titers shake off "rough" on a tube with a higher dilution than I could see microscopically, yet I found lots of what turned out to be junk by reading everything microscopically. So we made the change in hopes of finding real antibodies and avoiding junk. Obviously, this requires good shaking technique. That worked very well. Now, automation will be changing things again.

Be aware on UW quizzes that the answers are based on their policies, not always general practice. I never could get 100% on them! (Obviously, there's something wrong with the test, not me.)

Is it required under ISBT that syringe aliquot labels (the syringes would be filled and filtered in BB) have the ISBT format (4 quadrants with specific info in each)? What are other Safetrace/HBB users using? Our system prints syringe labels all nicely barcoded but not in ISBT format. Are these labels for some other purpose than just labeling the syringe since they also have patient info on them?

What is DEHP? Thanks.

I turned out a Lutheran antibody once and the OB asked me if we had an anti-jewish antibody too. Then he said, "I can say that, because I'm Jewish." I come from a whole family of A intermediates but I am not sure I want to volunteer my blood to everyone on this forum--I might run dry! University of Alberta used to have some good stuff on their TraQ (or whatever it was called) program. Does anyone know it is still there?

O neg units are no panacea for antibodies unless the specificity is for ABO or D. The worst scenario I can think of is a mom with a really high titer of say, anti-S, that was passed to the baby via placanta. Baby would have to be S neg or it would have stayed in the hospital recovering from the HDFN till most of the maternal antibody was gone. Then, if there is a trauma and if you transfuse this baby with S+ blood, you could get a hemolytic reaction--self-limited since no more antibody would be produced--but not particularly helpful in an already gravely injured child. Odds of this are extremely remote due to the rarity of moms with high-titer antibodies having babies that are antigen negative and are then involved in a trauma. Aren't babies under 4 months considered incapable of making new antibodies? Then you wouldn't have to worry about any that the baby could continue to make, at least till later. Maybe that was your point about continuing with O neg units??? We had a tragic case of post-partum depresssion where the mom shot 3 of her kids, including the 2 month old and 3 & 5 yr olds. One died with the mom, but the baby and the 5 yr old made it in to us. We got a specimen from the baby that was venous, but they had an IO in that they used for infusion before they shipped her out. So this question is not just for children's hospitals but could come up anywhere they might use IO for access. I don't know if it was the right logic, but I chose to give her O neg blood even though she was A pos and I had time to crossmatch so the receiving hospital could use the < 4 mo./only given O/ need not crossmatch or retest till 4 months old rule. I think I would be tempted to use it for the type--at least for the record--even if you continued to give O red cells.

Next question is on cryo for premies. We have instructions to add 10 cc of saline to a single cryo unit after thawing for a neonate. Is this common practice?

Wow, Gil. What a great posting on DATs. I am going to email it to some newbies as a great source for their education.

I was relieved a few years back when working with an OB with a warm auto to learn that such antibodies, if benign in the mom, are usually benign in the baby. (That's buried in Issitt somewhere.) Although interesting, it sounds like it is a non-problem clinically--expecially with the previous baby being okay. I wonder if the antibody remained between pregnancies or if it comes back with each pregnancy. Maybe she will volunteer to be checked 6 mo. post-delivery. Can't antibodies with lower avidity sometimes be partially washed off in the washing phase of tube testing? Since gel is not washed, maybe that helps explain the strength difference--the antibody is lower in avidity. Hope you don't need to transfuse her. She would be compatible with Ce neg units and you would expose her to Ec pos units by giving compatible units.

Does anyone know if all the sterile connecting devices out there are compatible with all the syringe sets? I can find SCDs made by Terumo and Haemonetics. Are there any others? What is everyone else using for an SCD and are you happy or unhappy with it?

Also, does anyone have any experience with the Genesis BPS syringe and filter sets? Are they just like Charter Medical's?

Does anyone know of an X-ray blood irradiator in which syringes will fit? Who makes Xray blood irradiators anyway? Just the one company (Raycell I think)? Also, does anyone know of a source of such an instrument as used equipment? I heard of someone that bought one a couple of years ago that was used and the price was much more possible. I might as well dream, right?

If you are doing gel titers you need to have informed your OBs that the titer values in their books won't correlate to yours as far as clinical outcomes. Gel titers of 16 could cause unnecessary amniocenteses without this notification.

Has anyone with the newer Massive Transfusion Protocols that include plts and FFP with the red cells as soon as possible found a reasonable way to issue their "bucket-o-blood products"? We won't have pre-thawed FFP so it will likely go out a little later than the red cells and plts. It seems like it would be good to keep it all together but we have temperature issues between red cells and plts and even freshly thawed FFP might be too warm to put in with red cells. So, any creative coolers out there?

Thanks Kay. Do you ever give plts to neonates? We might have to do that rarely. We don't have a sterile docker at this time and our supplier is 6 hours away, barring weather issues, and does not make plts from WB donations. If it is rare enough, we will probably just sacrifice an entire pheresis unit. Does anyone have pro or con on the Genesis Pedi-syringe Filter syringes and filters?