AMcCord

We are using a small Themogenesis and like it a lot. It gives us a quick thaw and has been pretty dependable. Very easy to use. We also have had a problem with corrosion in a pump seal but now recognize it in it's early stages because of the little quirks the equipment shows. Biomed stocks the part so we schedule the replacement and are not down for more than a few hours. It's only once every 18 -24 months. I think that was a design flaw that they supposely have corrected - that you could check.

We've been having a long discussion on a number of threads about what we are doing about ABO confirmation prior to transfusion. I'm having that discussion with our lab manager and we have reached an impasse. He wants to know - in numbers - how the majority are dealing with this problem. I'd like to see a poll to determine what the prevalent method is: 1. Retype the same specimen (same or different tech)? 2. Retype a specimen drawn at a different time specifically for blood bank? 3. Retype a specimen from another lab section that was drawn at a different time - meets blood bank labeling requirements? 4. Retype a specimen from another lab section that was drawn at a different time - has NO specific blood bank labeling requirement? Thanks in advance for your input!

BPDR applies to all testing done by transfusion services, as well as the blood center that draws the donor: all testing for types, screens, antibody identification, etc to get blood products ready for transfusion, the QC on the reagents you use, tagging the products, issuing the products, etc etc etc. So, short answer... it does definitely apply to a small transfusion service. Here's the web site for BPDR. It explains what must be reported (and that is one huge list of possible errors and omissions!) as well as how to report. http://www.fda.gov/cber/reading.htm We submit our reports on-line. The report part is pretty easy - just fill out their form with the requested information. The tricky part can sometimes be deciding what code to enter to identify your deviation. If you get it wrong, they will email and let you know what code you should have used. If you catch the error/omission prior to issue, it is not reportable. If you catch it after issue, even if not transfused, it IS reportable. If you submit a report and it wasn't really a reportable event, they will let you know that, too. It really is not that big of a burden once you figure out the process. A small facility should not have very many reports in a years time.

I ask for an auto with each test method used. That means we run the auto 3 times if we end up using gel, LISS and PeG. It is quite possible to detect an autoantibody with one method and not another. If you don't realize you are chasing a warm or cold auto in PeG because you only did the autocontrol with LISS (and it was negative), you may waste a lot of time and energy looking for a specificity that isn't there. Remember that a warm or cold auto may not be reactive with all cells using a given method. It may look like it's a simple, straightforward allo on the antibody screen and even with the panel, except you just can't quite make it fit any particular specificity. I've seen a number of warms that behaved that way. A positive autocontrol suggests that what looks like a simple ID up front may actually be a warm auto. When I take things up a step to PeG, then I see broader reactivity or in a couple of cases, an actual warm auto specificity (like auto anti-K, auto anti-e). I think that doing the auto with the panel gets your investigation pointed in the right direction right from the start.

Have you seen the thread here titled 'Blood Bank Automation'? I didn't find anything in the literature specifically comparing the instruments but did find a comparison of the methodologies in Immunohematology, volume 22, number 4, 2006 - In search of the Holy Grail: comparison of antibody screening methods. There is another, older article in Transfusion, Volume 41, May 2001 pg 621-626: Optimizing pretransfusion antibody detection and identification.......... Hope this helps.

We do the same as KWenz.

We check resuspend, cell button, etc. daily when we wash our daily tube QC.

We do a retype if an order for added units is received for the same specimen, though no repeat on the antibody screen. Yes, we document it but we do not charge for it. We have a retype policy, but that is a separate issue in our minds and applies to the original crossmatch order for patients with no previous record. We do not do a DAT routinely with crossmatches. We do require a DAT and/or auto with antibody ID workups. We have a couple of physicians (oncologists) that ask about the auto on some of their patients when they transfuse them, but I simply tell them that they have to order that test if they want it. I will not start doing it on all (or even some) crossmatches again - no way! We are a 186 bed hospital in the Great Plains and transfuse approx 165 units a month to a broad range of patients.

We use a Thermogenesis thawer (2 unit model) and get 2 units in 12-14 minutes depending on the volume of the unit. It doesn't seem to affect the thaw time whether you thaw 1 or 2. They also make a 4 unit model, but I don't know whether or not your thaw time would increase with more units. I don't think they make a bigger one.

From reading I've done in various publications, my understanding of the 'rule' about using outdated rare antisera is that you may do so, with proper controls (of course), in "an emergency" or if the product is not commercially available. That would seem to make the routine use of outdated antisera a no-no. However, I don't see why you couldn't use the outdated stuff to 'pre-screen' donors. When you find the number of antigen negative units you need, use the indate reagent to confirm the antigen status of the units. That would save you a lot of antisera if you are not ordering antigen screened units from your blood supplier. You can also 'prescreen' donors using your patient's serum/plasma, if they have a nice strong antibody and you have enough sample. Crossmatch multiple units to find some which are apparently compatible, then use your indate antisera to confirm the antigen status of the donor. That's the reverse of what we normally do. But as long as you fulfill the requirements for crossmatching patients with antibodies, it doesn't matter in what order you do the required tests - i.e. antigen negative and AHG crossmatch compatible. We froze serum from a frequent flyer patient with anti-E and anti-Di(a) and used it to prescreen donors for her. Saved us a lot of antisera. You can prepare reagents in-house from sera, as long as you can meet the dilution criteria the FDA sets for the antibody in question. The criteria list is in the Technical Manual in the chapter on alloantibody detection and identification. I would think that the validation/jquality requirements would be too much hassle to be worthwhile for most of us.

According to Petz and Garratty, in the study that is often cited as a basis for transfusing washed red cells to CAS patients, the patient in question had a serum complement level that was "always low". The authors of that study speculated that the plasma transfused with the RBC unit provided enough complement for the hemolytic reaction the patient had following transfusion. (Kind of like adding complement to a test system, only this system was in vivo.) Petz and Garratty say that they would like more documentation of this sort of phenomena. They note that serum complement is ordinarily not reduced in warm- or cold- antibody AIHA. They think there should be more information available before routinely recommending washed red cells for these types of patients. I suspect that a number of things we do are based on shaky foundations like this.

Interesting. We've had a couple of patients it might have been worth trying on, but we don't have the ability to wash units.

If it doesn't look like a warm auto, I like to go with a tube/PEG panel after the gel to rule out the major alloantibodies. If I suspect a Jk, I take a close look at my homozygous cells and sometimes run a panel of enzyme treated cells in tube. I also watch closely for E and K, since gel is known to miss those on occasion. I read the tubes with a scope when I'm working with weak reactions (yes, I know, hopelessly old-fashioned!). I also pay attention to those little guys lurking on the sides of the panel sheets or listed in the additional typing sections - some of my confounding reactions have turned out to be Coltons or a Diego or other weird things. I've seen these teamed up with a more common antibody and sometimes solo. If it looks like a warm, but a weak one, I might still do a PEG panel. I have picked up a few weak alloantibodies rising above the 'noise' from the auto. Drop back to LISS if the PEG revs up the auto too much. AND don't overlook the possibility that you are looking at a cold antibody that is reacting very weakly outside of its happy zone. I've been called in to work on weak, nebulous reactions that have turned out to be Le(a) or M antibodies. We tend not to think about those with gel but they can show up. If it looks like it might be one of the cold antibodies, try setting up a quick screen IS and/or a 20' RT incubation with serum to point you in the right direction. When I've satisfied myself that I've ruled out the major alloantibodies, I do an AHG crossmatch and transfuse the unit that is compatible (and antigen neg for anything else I've ID'd). I report an antibody of undetermined specificity. If I were closer to my reference lab I might punt sooner and let them do more of the work.

I had a hemotologist request washed red cells for one of his patients with Cold Agglutinin Syndrome secondary to leukemia. He stated that he didn't want 'extra proteins hanging around' for his patient to react with, but didn't go into any details. Neither he nor his partners have requested washed cells for WAIHA. I did some reading (Immune Hemolytic Anemias - Petz, Garratty) and am speculating that my doc was using the rationale that washing the cells would remove complement, thus reducing hemolysis. Petz and Garratty talk about work done based on the treatment of one patient with CAS who was noted to have 'low complement'. The reference goes on to say that they would not recommend the use of washed RBCs based on this rationale without more information/documentation. Maybe this is the reasoning being used to transfuse washed cells to patients with positive autos/incompatible crossmatches...?

I was told by the money people that for Outpatients my crossmatch charge has to appear on the same day as the infusion charge - in other words, the date of service refers to the transfusion, not my test date. If the outpatient is done under a recurring visit, which the majority of my outpatient transfusions are, then the crossmatch date and infusion date don't seem to have to match. We do bill the product portion of the charge on the infusion date. This is apparently how it has to be for Medicare if you expect to get paid. The same rule does not apply for inpatients.

You also have to hope that admitting correctly admits the correct patient. We had 2 women here with due dates within 1 month of each other. Their first and last names were the same - though one last name was spelled with an S where the other name had a Z. The birthdates were almost identical - same month and year, only 2 days apart. They lived in the same trailer park, so had the exact same street address, the box numbers were different by 2. Their husbands did have different names, thank goodness and we had a SS# on one. One was admitted as the other to deliver. L&D slapped an armband on for us, grudgingly - only because we get cranky about it and won't draw lab specimens without it. Guess what?!? The blood type didn't match our records for who we were supposed to have. We (blood bank) figured out who was really in the L&D room upstairs by speaking with the patient's husband (language barrier) but then had an impossible time getting L&D and admitting to correct the admission error and get things straight!!! All the calls about who was who kept coming to me. L&D didn't think any of this was a problem that concerned them at all - they didn't see any need to talk to the patient or to assist admitting in fixing the problem. When the other patient with the same name came in 3 weeks later for some outpatient lab work, we discovered that the record had still not been corrected. We had to go to the head of admitting to fix the problem. We knew L&D wouldn't have if she had come in to deliver. Bottom line...WE have to be vigilant cause there are far, far too many people who just don't get it!

We are also in the process of bringing ECHO into our lab. We asked for a reagent lease contract which takes it off the capital funding list (outright purchase was NOT an option for us, either) and the pricing over the life of the contract was actually cheaper than what we have been running over the last couple of years with our current methods.

The lastest issue of Transfusion (Vol.48, No. 3, March 2008) pg 411 has a commentary titled Red cell age and loss of function: advance or SNO-job? It is going to be interesting to see where this goes.

A 70% ethyl alcohol rinse, followed by a good rinse in DI water is used to decontaminate the diluent pump used with gel testing. That could be an alternative to bleach.

I've seen it 4+ strong by gel in a sample drawn by the nurse immediately after giving the injection. I've also seen it 4+ strong in several patients that were given their injection at the office and sent to us to be drawn - draw time 30-60 minutes post injection.

There was a requirement for RPMs when using the round-and-round, end over end type of rotators back in the good old days. I got the number from the ARC way back when an FDA inspector dinged us for it. We have long since gone to the flat type agitator that comes preset from the factory (using that required number no doubt). We are still checking RPMs daily but since the agitator comes preset and the manufacturer makes no recommendation for a daily check, I think maybe the quarterly check would be sufficient to insure that the thing is still functioning within it's parameters. Why is it we make work for ourselves by hanging on to old habits?

We use a Thermogenesis thawer. They come with 2 or 4 slots. We get 2 units in about 12 minutes. The FFP goes in a neoprene pocket, so there is no contact with the bath water and if you break a bag, the mess is in the pocket. Pop a fresh, spare pocket in and keep on thawing - no bath cleaning as long as the pocket is intact.

I see it the way Gil does, though our previous Medical Director did not. That is why I was so delighted to hand it off to nursing and why the lab manager was quick to agree with me. RNs are better equipped to handle any complications, administer meds if necessary, etc. etc. All orders, documentation, any reports - all done by the OIC. They do bring the bags down to us for disposal in our waste but red bagging is really all that needs to be done. We handed over our equipment and Materials Management stocks their supplies. It has worked well.

We used to do the therapeutic phlebotomies. Appointments were required for outpatients. IP stats were rare and done in the patient's room. We tried to talk them into waiting until day shift when possible though I did have to come in a couple of times on evenings to do one. We usually had someone trained to do them on both weekend crews, so we could handle those requests, too. About 18 months ago the nurse manager of our Outpatient Infusion Center asked about taking over TPs. She had been to a conference and discovered that it was something that was done in units like hers. I was delighted to hand that function over to OIC! I think about 30% of her staff is still unhappy with her for doing it . I trained a core group of 4 RNs on the OIC unit, gave them detailed info on the care and feeding of our regular customers and held their hands for a couple of months, if asked. They are doing fine. Their schedule allows more flexibility for OP appointments. IP requests are arranged with them on a case by case basis. I am thrilled to get rid of the whole process, though I do miss seeing some of the regulars - you do get pretty acquainted with some of them.

We do it exactly like bbbirder.