AMcCord

You are right about that, but apparently Health and Human Services doesn't read the same words we can.

Our procedure states exactly how outdated cells may be used - selected cells only, how they are to be controlled, how the controls should be documented, what the expected results of the controls should be and how old the outdated cells may be (no more than 3 months outdated) when used. I've never had a problem with an inspection, including past inspections by the FDA.

We've also seen the flocculation problem with some patients - I call it PeG clouds. The protein explanation seems reasonable to me. The patients we have problems with seem to be oncology patients or elderly patients with multiple problems. I've found washing x4 to be helpful, but I've never seen one that needed more washes than that. Something to be aware of - thanks for the thought!

There is another thread going that has been discussing this - 'IS with AHG Crossmatch'. The tail-end of the discussion has an attachment of a CLIA Network Newsletter July-August 2009 (US Dept of Health and Human Services). On page 2 of the newsletter is a section of 'Frequently Asked Questions' and the requirement (or not) of the immediate spin crossmatch is question #1 or 2. The answer to the question references 21CFR 606.151 (a) through (e), with specific attention called to section ©, which is the immediate spin crossmatch section. The answer then states that failure to perform an immediate spin crossmatch with gel testiing should be cited as out of compliance with rule D5551. (Gel testing was specifically included in the answer.) If your facility takes money from Medicare, you are required to meet CLIA requirements. Our CLIA inspections are done by the state. We actually had a visit from them (the state) - Surprise! - last year shortly after our CAP inspection. Apparently they pick a percentage of CAP inspections to follow up on to check up on how well the inspection was done and to make sure that the facility is CLIA compliant. The CAP inspection is supposed to be covering the CLIA issues (?? I guess??). So...that's what I know about it. We do, by the way, perform immediate spin crossmatches for all - including when we used gel.

We are JCHAO inspected and, at this point in time, RhoGAM is still in Blood Bank.

I agree with the above.........

Transfusions are documented into an electronic medical record here. One thing that the transfusionist must document is that she/he reviewed the physician's order prior to transfusion. Do some of them just say 'Yes" without really looking? I'd bet on it, but I haven't been made the policeman...yet! Hopefully not ever because I already have way too much paperwork.

Nice form Rashmi...thanks.

Evil thought!

Yes, I've heard that one! You wonder what they would think/say if a family member was in a bad accident and all of their blood was leaving the world without them.........or with them, worse case scenario. They don't think, that's the problem.

We avoid giving Rh Pos pheresis platelets to Rh neg women of child bearing age and would also avoid it for children. We would offer RhoGAM to these patients. We do not offer RhoGAM to other Rh neg patients who receive Rh pos platelets. We've used pheresis platelets exclusively for the last 5-6 years (low volume, maybe 150 units per year) and have seen one patient develop anti-D from a pheresis platelet - an oncology patient, no less, and the last person I would have expected to do it to us! The unit she received was not red tinged, so the RBC count would have been very low. Naughty patient!!!

You're welcome...

Just saw this one this week as a comment on a patient's admission paperwork. "According to nursing home, patient is to do CPR." My question is this...........Is the patient supposed to do CPR on other patients in need or is he supposed to do it on himself?

We do pretty much what David does with the RhoGAM problem. Echo panels are very slick, though, and the RhoGAM anti-D will ID nicely. We switched to PeG for tube testing once we went live with the Echo. My experience from my validation studies was that LISS was too different (weaker) in it's ability to enhance antibody reactivity as compared to solid phase for many of the samples I used. We missed too many real live clinically significant antibodies with LISS that were picked up by the Echo. Peg has always been our go-to method for weak antibody ID, RhoGAM anti-D included, so I made the switch to PeG for all testing. I feel much better about calling an Echo reactive screen negative after getting a clean screen with PeG.

Bacteria may be present in the unit from the collection process or because of bacteremia of the donor. Once the unit comes out of the cold and starts to warm up, the bacteria in the unit (if any) can start to multiply. The 4 hour time limit for transfusion was chosen to play it safe - if bacteria are present in the unit from the beginning, they won't multiply enough to cause problems for your patient. If bacteria were introduced into the unit when it was spiked, they won't multiply enough to cause problems for your patient. Whether the infusion was interuppted or not, the time is still 4 hours from the time out of the fridge.

The tube is angled at 45 degrees. Sorry, I should have been more specific.

Transfusion Reactions states that TRALI is diagnosed by excluding everything else, so that makes it a tough call for the physician. The same reference also notes that respiratory distress, cyanosis and tachypnea are prominent features in circulatory overload and that tachycardia and hypertension are usually present. Another possibility to look into...did they do chest Xrays? If heart enlargement was noted post-transfusion but not pre, that could be an indicator of volume overload. Evidence of pumonary edema on the X-ray could be another indicator. TRALI might show itself as severe bilateral pulmonary edema with severe hypoxemia, fever and mild to moderate hypotension may be present. (The hypotension associated with TRALI may not respond to IV fluids.) There is a 'classic white-out' pattern on the chest films of some TRALI patients. BUT There are no definitive tests according to anything I've read - lab or X-ray. Another reference you can check out for free, I think, is the CDC Hemovigilance project. Google The National Healthcare Safety Network (NHSN) Manual Biovigilance Component. Appendix B of the manual portion is a nice listing/definition of reactions with signs, symptoms and diagnostic test recommendations. You can also get the same information at www.aabb.org.biovigilance - though I don't know if you have to be an AABB member or not to access it there.

We have a Sanyo ultralow in our send out area that seems to work great. If you can get one with a chart, it would be worth a look (I don't know if they come with the chart option). We have a Revco in blood bank and I would not recommend that brand. Trouble trouble trouble.

I played with the Tipmaster when we started gel years ago and went straight to the electronic version. We never used the Tipmaster for patient testing - seemed cumbersome and way too much irritation and effort for my thumbs.

Judd's Methods in Immunohematology has a section on cell separation with several methods. I like the centrifugation method. Simple and inexpensive to perform. Usually works pretty well.

A BNP could help differentiate between TACO and TRALI. The BNP would be elevated for TACO and not for TRALI. Of course, it would be best if you have a pre-transfusion sample BNP result to compare with, to see if your patient was already in heart failure or not. An excellent reference for the topic would be Transfusion Reactions, edited by Mark A Popovsky. It's an AABB publication.

We would just give them the whole unit. Splitting the unit has labeling requirements - barcode labeling requirements - that are not practical for a 'once in a blue moon' situation.

We also receive ours clotted in large tubes. The information we got for specimen prep was to mix the (clotted) specimen, tip and hold the clot tube to about 45 degrees and pull off 2 ml of sample from the top long side of the clot tube (if that makes any sense to you) with a pipette - not from the bottom of the tube. Your goal is to avoid the clot. Put the specimen into a labeled 12 x 75 mm glass tube and run a pair of applicator sticks through the sample at least 3 times (new sticks each time) to collect any small clots. If I'm getting small clots, I repeat until I have a couple of pairs of sticks come out clean. Spin the sample as you would any other sample. Put it on the instrument using a PED rack and you are good to go. We don't always get a full specimen collected, so I experimented with the sample volume. I found that 1.5 mls (and sometimes just a tad bit less) ran just fine, also.

One other point to consider...how reliable is your source? Does that source have issues with the prospective tech that would cause him/her to make a false report for whatever reason?

That will be a very welcome addition to the lab info world.