AMcCord

The comments about trivial pursuit and looking at the 'strange and rare' are dead on. I recommend all the books mentioned plus The Blood Group Antigen Facts Book/Reid and Lomas-Francis for concise info about the strange and rare category. If you are not familiar with the blood center side of things, try to get some time in at a blood center - donor room, pheresis, QA, processing. If you are not familiar with the transfusion service side of things, get familiar with the practical side of that. I made sure I was pretty familiar with methods for doing almost anything you could think of (and stuff you had no idea anybody ever did!) - reagents, rational, testing protocol, QC, etc. - that paid off big time for me. Dr. Judd's manual (2nd ed. out of print) was very helpful. Put some time in studying and you can do it!

There are good arguments for using both single dose and double dose expression of the antigen. The most important thing is to be consistent. Choose one or the other and stick to it. The Technical Manual discusses cell selection in the Methods section on HDN 5.3 in the 15th edition.

We used 15-20 mL saline to pool cryo. Our cryo units average about 5 mL each, so we really needed a little extra volume to help things along. Our pooling worksheet include a spot to document saline lot# and volume.

I suppose your comfort level would depend on the method you use. If you are a gel user who has missed an anti-K, you might be more inclined to use more ruleouts. I feel pretty secure with only one if I'm using PeG.

I was told on Tuesday morning that Immucor anti-C should release by the end of the month, just waiting for the FDA to sign off. I ordered anti-IgG that same day and was told...sorry, backordered. So you got a little lucky with that.

We were cited for this one a number of years ago. We had to institute a mandatory yearly training requirement for nursing on this subject. We got their cooperation when we told them it was required for regulatory compliance (Joint Commision is a wonderful weapon :tongue:). I borrow a copy of the training roster (many! pages long) as documentation for inspections. As a part of this training they get a case study for a transfusion reaction, a different type each year, with questions to answer. They also get a general review of institution policy from staff development. Nursing manuals include an SOP for recognition of and response to suspected transfusion reactions which includes a section of signs and symptoms. The quiz is evaluated by someone from staff development so they can see who needs a refresher or if they need to do some focused general education. As the blood bank supervisor, I am involved with the development of their training exercises and SOPs for transfusions (at staff development's request). I am sometimes asked to develop the case study and sometimes they simply ask me for a review of what they have worked up. If we've had a real case where something was done wrong (or very right) or if there seems to be a common problem, this becomes the focus for the yearly exercise. We are pretty excited for future reviews. The hospital has recently purchased an iSTAN for staff education. If you aren't familiar with iSTAN, this is a computerized human simulator that can be programmed to display symptoms, make responses to stimuli, etc etc. Very cool training tool! We plan on setting up iSTAN to simulate a transfusion reaction - he/she could show symptoms for TRALI or AHTR or whatever you choose. Pretty longwinded...sorry!

Check the Circular of Information. In the section titled 'Instructions for Whole Blood and All Components', #4 says "All blood components must be transfused through a filter designed to remove clots and aggregates (generally a standard 170- to 260-micron filter)." Of course that doesn't cover the patients/products who require specialized filters. The thing about this that would concern me the most is the fact that the nursing service makes unilateral decisions about blood products without consulting with the blood bank Medical Director. I've harped on that here to anyone in nursing management who will listen to me. I think I've made good progress but once in a while somebody goes all independent on me!

I would also appreciate a copy of your checklists. Thank you!

If your patient is having a problem with Keflex (cephalosporin), your DAT could be positive for complement only and your antibody screen negative because your reagent cells (and donor cells) are not coated with the antibiotic. I've seen 2 cases of severe anemia with cefotetan that behaved this way. The eluate was hugely positive with antibiotic coated cells and negative with uncoated cells. Interesting and scary!

Cool! Where do you get them?

TO MANY CLOCKS!!!!!!

We are the same, except 1hr 30 minutes for STATs. Our actual average turnaround time for Stats is between 45 and 60 minutes but we gave ourselves a little wiggle room for getting the specimen drawn and to allow for times of overload with AM surgical cases. The nurses generally pay little or no attention to our 'promised service' times and start calling before the phleb gets back with the sample.

You are correct - poly AHG detects complement, fulfilling the requirement to detect C3. You just need to do the complement QC on the poly to prove it works for the C3 as well as the IgG. As to the control cells for complement, Oh ya, I'll admit it! they can be a wee bit 'touchy'. About once a year we have to request a fresh shipment - if they come in during really really cold or really really hot weather, they sometimes don't work very well or don't work at all. Seems like some lots are better than others, too. It helps to have a really light touch when you shake them off. I tell my MT students that it's a good test of their tube shaking talent if they can get a nice 2+.

Not to beat a dead horse, but.... TRM.40655 asks 'when a direct antiglobulin test is ordered...does the test system allow detection of RBC-bound complement as well as IgG'? Then TRM.40210 asks 'when performing an antiglobulin test with anti-C3 antiglobulin reagents are C3-coated cells used in all negative antiglobulin tests'? (I haven't seen my new check list yet, so I'm going on our last one and an inspection checklist we did this spring.) When you are doing a DAT which has been ordered by a physician, it is for diagnostic purposes - you are seeking to detect not only IgG but complement as well. Complement coated red cells are significant for oncology patients (treatment and prognosis, as I understand it) and patients with anemia-cause under investigation, as well as CAS, certain drugs, etc. If you are not comtrolling the anti-C3 activity of your poly AHG, how can you be sure that a neg DAT is not a false neg for complement? (Have I ever seen AHG fail QC for either IgG or complement?... no, but I don't think CAP would buy that defense from me about reagent QC .) When this whole complement QC thing first appeared on the checklist a few years back, the lab manager and I debated the requirement for C3 coated cells. I called CAP to get a ruling on that and was told that I did need to use C3 coated cells with poly AHG when doing DATs (ordered by physician) for diagnostic purposes. So, I don't think you can meet the intent of 40655 and 40210 w/o using C3 cells. Immucor sells them - they are on my standing order along with regular Check Cells. Yes, it is an extra expense. If you don't get many orders for DATs, your simple option might be to send out any ordered DATs and not have to worry about it. Any other AHG testing, do under a protocol you define to exclude detection of C3.

We have a 2-door Helmer we love. No problems ever. When I was setting it up, I found their customer service department to be extremely helpful. We have just gotten a new single door model from them.

Spinning a gel card prior to use is OK and is necessary if the cards got shipped (or stored:mad:) upside down or on their sides. Once a patient test is set up, it's one spin and one spin only. It is quite possible for a weaker reaction to appear negative if respun. If the card looks like it didn't get spun properly - stuck at an angle, for example - the test must be repeated, not respun. The product insert is very explicit about not respinning tests.

I think the jury is still out on this one. I haven't run across any information that refers to red cell survival studies for warmed vs not warmed blood. Some years ago, we had one patient with CAS so severe that her serum was olive green and her skin had a green cast all the time. Her antibody titered out so far the dilution error had to have made the results a flying guess at best. We transfused her regularly with a blood warmer, but she always had problems. Then we started asking the unit to crank the thermostat up in her room as far as it would go and pile on the blankets. Every transfusion done that way went fine. Based on her and all the other patients with cold autos who have done just fine without the blood warmer, we recommend the warmer on a case by case basis and it's pretty rare that the warmer is recommended. If a physician orders that a warmer be used (and that's a very rare event), we don't argue. In Blood Transfusion in Autoimmune Hemolytic Anemia, Petz and Garratty say "in the absence of extensive data, logic must prevail" - to paraphrase, properly crossmatched blood can probably be given slowly without warming with no problems but for seriously ill patients and those with severe PCH or CAS, use of a blood warmer would be indicated. And further, it would be logical to keep the patient warm..... That approach seems 'logical' to me.

We ask them if they think they can infuse the product completely by the expiration time, stressing that they cannot exceed that time. If they say 'Yes', then we check out the unit with the instruction that infusion must stop at 2359 (or whatever the expiration is), whether infusion is complete or not. If they say 'No' or seem at all uncertain, we issue a different unit. We haven't had any problems - nursing service has been very cooperative.

Consistency is a problem in regards to anti-M titers. The major OB/Gyn practice in my area has most of their prenatal work done here, but some of their patients go to a neighboring facility for their prenatal workups for deliveries that will happen here. We aren't currently doing titers for anti-Ms that are AHG nonreactive but the other lab does. Makes for some interesting discussions with the doctors. So far I have managed to persuade them to skip the titer.

My quandry is....do I do a titer for pregnant patients if the antibody is non-reactive in AHG at 37C? The old wisdom says no titer, but this article makes me uneasy. On the one hand, I hate to rack up big bills for these patients. On the other hand, maybe the (ultra) conservative course of doing the titer is best.

Gotta give mom RhoGAM even if they are weak D pos, so I would be really cautious about putting a cut-off in place in regards to that. You could still call them Rh neg for the sake of transfusion.

That is on pg 548 of the 15th ed of the Tech Manual under Postpartum Administration/Postpartum Evaluation (chapter on Perinatal Issues in Transfusion Practice).

The Technical Manual says "preferably within 1 hour after delivery". I had a PA (pediatric practice) deliver here who made us come back and redraw her because we got our sample about 50 minutes after delivery and she insisted upon 'exactly' 60 minutes post delivery of the placenta. Whatever - we aim to please!

I'm also not ready to blame the kit. I had a different tech repeat the fetal screen with the Immucor kit after receiving the results of the survey. She stated that the 'rosettes' seemed atypical in appearance in the sample in question, more like loose aggregates than the tight rosettes we usually see and different in color. The positive control was normal in appearance, as was a sample we prepared by adding the cells of a newborn to an adult male. Based on the premise of better safe than sorry, she also would have reported the fetal screen as positive, with a KB to follow. We have never had a survey failure prior to this for fetal screens. I am more inclined to place the blame on the sample. It will be interesting to see what the followup is for this.

I would also appreciate a copy of the form. Perhaps you could post an attachment in this thread. thanks!