AMcCord

We had stopped doing cord bloods for O Pos moms until the arrival a couple of years ago of a fresh out-of-school Family Practice doc. He insists on it and he talked one of the other docs at his practice into ordering them also! One of his mentors must have been stuck on ancient history. Other than that, we only do cords for Rh neg moms. If they have an antibody, we often get no orders on baby except CBC and T Bili. Sometimes I get the phlebs to draw me a specimen with that CBC/Bili so I can do a DAT for my own satisfaction.

We reconfirm antigen typing when the units come in for the reasons everyone has listed. We do send a properly ID'd specimen to our reference lab, they won't accept anything that is not properly labeled - good for them, in my opinion. If we send a specimen and request suitable units, the report comes back not as crossmatch compatible (or whatever is appropriate for the circumstance) but as 'pre-selected for compatibility'. A note on the report states that all components must be crossmatched at the transfusing facility, their results do not act as the test of record for the crossmatch, etc, etc. Since we stock a lot of antisera and usually only send out recently transfused warm autos and oddball/illmannered antibodies, we sometimes send segments of units we have crossmatched and that appear compatible or least incompatible. Once we get the reference report faxed to us, we are usually ready to transfuse without much, if any, additional testing. Most importantly, we don't have to wait for units to ship which reduces the possibility our specimen has expired and speeds up getting the product to the patient. Since we are 150 miles from our blood supplier/reference lab, this can really speed up the process. If the reference lab used adsorbed serum for the compatibility 'screen', we report out our crossmatch as incompatible (which it surely was for us) and release only the least incompatible.

Our policy fits in with the last 2 posts. I've only seen one anti-D produced in an oncology patient.

Good question! Makes me think on a Monday morning....... Mother's DAT may be due to an autoantibody which is capable of reacting with the indicator cells. If the auto does not have an anti-D specificity, it could have a more generalized specificity that could be reacting with the indicator cells. I wonder how common this problem would be? - not very high incidence at all, I would quess.

I have seen 2 patients who apparently have anti-Cob alone and 2 patients with anti-Cob + one other alloantibody. (Three of them were first ID'd all in one week! How lucky can you get?) One of the solo anti-Cob patients had been recently transfused by us, his first transfusion ever. When we ID'd the Cob, the timing from that first transfusion was such that I would have expected to see anti-E or an anti-JK if he had made one of those also. The other solo case was a multiparous woman who though she "might" have been transfused elsewhere in the distant past but she was not a good historian, so we didn't attempt to track anything down. We ID'd the anti-Cob only, transfused her several times over the next few months and never saw evidence of any other alloantibodies. Of course, both of these folks could have had antibodies to low incidence antigens that we never saw. Guess those 2 antibodies forgot to read the book that said they were supposed to come with friends.

We have the transport issue you talk about and it's a whole lot of fun trying to get information out of the receiving hospital sometimes. Some facilitites we may transfer patients to refuse to acknowledge that the patient ever came in with any product at all. Since they "don't receive the product", they tell us that everything is our problem and has nothing to do with them. We figure on eating the charge in cases like this. If we transfer to a facility who uses the same blood supplier as we do, we can transfer the products we send out packed in a box to the receiving hospital. We get credited for the product by the supplier and the receiving hospital gets billed for it. If the patient rolls out the door with a unit or units hanging, we bill for those. We like it better if they send them out with the product running:D! We also ask them if they are really really sure they need to send blood with the patient - it's a short flight and there is not much time to run blood. I don't think there is any good way to deal with this unless your facility has its own life flight and can get the coolers with product back.

There have been some very lengthy discussions on what to call a patient - Rh pos or Rh neg - based on strength of reaction with anti-D on the AABB site and I think I've seen one on this site. The Technical Manual says it's a grey area for perinatal issues, so what us mere mortals are supposed to do.................?!? A growing number of facilities choose to call any patient who types 2+ or greater MACROSCOPICALLY (or 3+ or greater in gel) as Rh pos and any patient who types as less than 2+ (or 3+) as Rh negative. Folks who are typed as Rh neg by these rules are given Rh neg blood and RhoGAM. The rationale is that without using molecular techniques, there is no way to know for sure who is going to be the patient with the right variation of weak D to form anti-D. Any positive result on a cord blood, no matter how weak, means mom is a candidate for RhoGAM. Again, without molecular techniques to determine what version of D baby has or even if that weak variant can truly stimulate production of anti-D, safe is better than sorry. We are still wrestling with this subject. You might check out what John Judd has to say on the subject, though right at this moment, I can't give you a specific reference. Mabel...can you help us out with that?

Weak D in AHG phase can be almost any strength. I've seen samples that test +/- and I've seen samples that test 2+. Remeber that there are several 'causes' for weak D. Your patient could have a low number of 'normal' antigen sites or could have a variant structure D antigen. The strength of reaction (or failure to react) can depend on which anti-D antisera you use. If you check your package insert for the fetal screen, it will specify in limitations for the procedure that it must be performed only on the blood of a known D neg mother of a D pos child. If the mother is weak D positive, agglutination provides no info about how much feto-maternal hemorrhage has occured in these cases. The other thing to watch out for is that it also won't provide valid results if the baby is weak D positive. A negative test can occur with a large feto-maternal hemorrhage - those weak D baby cells may simply not be detected. We flag our prenatals for weak D positive mothers with the comment that a Kleihauer-Betke is required. Saves confusion if the baby comes on the evening, night or holiday shift and there isn't anyone handy to ask about it. There is one more thing to watch out for. If mom has a positive DAT, that will cause the fetalscreen to be positive. A Kleihauer-Betke is required for detection and quantitation of fetal cells in this case, too.

The fetalscreen or rosette test is a qualitative test for detection of fetal cells in maternal circulation. If the fetal screen is positive, a Kleihauer-Betke or flow cytometry is done to quantitate the fetal cells for calculation of the RhoGAM dose. If the screen is negative, 1 vial of RhoGAM is administered.

We run diluent controls daily. Tube 1 is any of the screen cells + diluent in place of patient serum for a negative control checking for contamination of the diluent. Tubes 2 and 3 are an Rh neg cell (patient cell or donor segment) diluted with diluent to 0.8%, then tube 2 tested with diluted anti-D (negative) and tube 3 tested with diluted anti-c (positive). Tubes 2 and 3 are to QC the enhancement abilities of the diluent. These are in addition to the postive and negative controls we run to check the screening cells themselves.

We've given a number of Rh neg patients Rh pos platelets over the years, though only a couple of them were women of childbearing years. Only one of our patients developed anti-D and she did it after receiving 1 single donor unit. She, of course, was one of our young women. Fortunately, pregnancy was not something we had to worry about in her case. This woman was a big responder - she developed 3 antibodies with red cell transfusions and then added the anti-D with the platelets. Our oncologists refuse the RhoGAM - usually the comment made is about the lack of reimbursement for using the product on elderly or male patients, as in Medicare says it's not indicated for that use.

Our gel use is all manual and we have definitely seen the problem. Sometimes partial covering of a well or two. Sometimes all of the wells on a card. I've been using an applicator stick to rim out the film on the worst ones.

I have assumed that the AABB Guidelines were written with tube testing in mind. Does anyone know whether gel testing was a consideration when the quidelines were written? Just curious...

I believe that the pass rate for 1st try non-SBB school candidates is usually around 50% or less, so try again. It is possible to pass. I agree with the comment about trivial pursuit. They throw a lot of very obscure things at you, probably to test for depth of knowledge. Study deep! Issitt is a great source as is Geoff Daniels - Human Blood Groups. Good luck!

We were due 10/8/07and got inspected 9/23/07 (Tuesday). They came with 8 people (from a hospital under 200 beds to us with under 200 beds) - we wondered who was home minding the store.

I took my exam about 10 years ago, also. I agree with the others - it is tough for those of us who don't go through a formal program but you can pass it! I would definitely recommend the Gult Coast last chance review if you can swing it or something like it. I was lucky enough to be at the right place, at the right time, to do a one-off review course offered by UNMC with 80 hours instruction and they got materials from the SBB program in Galveston/Houston. Extremely helpful stuff. I studied every day for a year and I walked out of the test site with no idea if I had passed or failed - I think I was in shock, actually! In addition to Issitt, the Tech Manual, and CFR, I would recommend Mollison, Human Blood Groups by Geoff Daniels and The Blood Group Antigen Facts Book by Reid and Lomas-Francis. Although Harmening is intended for MLT/MT students, I did find it quite useful as a good broad review of everything. I also had a current anesthesia text, which had some useful tidbits. Immune Hemolytic Anemias by Petz and Garratty is another good source. I would try approaching the Red Cross. Our ARC regional center was a partner in the UNMC review. They provided a time slot of 2 days for most of us in the review program to spend time in their donor room, the apheresis center, their QC department, component lab and reference lab. My exam had lots of donor related questions on apheresis - my time with the ARC is what got me through that part. My exam also had lots of donor testing questions (HIV, Hep), itty bitty obscure detail questions about red cell antigens/antibodies and technical questions about methodologies like monocyte monolayer testing, use of DTT etc. Which reminds me of another great book - Methods in Immunohematology by John Judd - this is a cookbook of every procedure you could ever want to do. Good luck!

We also use tube testing for prewarms. I just didn't have very good luck with gel on the samples I've tried.

Well.........what they do here is PUNT! They send the patient off to the big city to see a specialist. The specialist orders the same titers we were going to do anyway and no matter what the antibody, if the titer hits 8 the specialist does an amnio. The fact that there are no facts doesn't seem to bother them at all. It's more the 'cover my rear' policy. Of course, when it comes time to deliver a baby, no one has the least thought of letting the Blood Bank know that antigen negative blood might possibly be required. It's all a surprise! Please excuse my cynicism .

Same for us.

We have patients who ask what color the product is - if it's yellow, they will accept it and if it's red (blood), they won't. On the consent, they add what products specificially the patient will accept - the only one I have personally seen, the patient handwrote that on himself with signature and date. This is also very explicitly charted by the nurse. Many will accept RhoGAM after they have asked us to explain how the product is manufactured. We also have a file of official material provided by their church to educate ourselves about their doctrine. We have seen a few JW patients whose physician's wrote orders for blood products without discussing that whole 'blood thing' with them. The first anybody knows about this is when a consent is presented and the patient declines to sign it. We have already started work and have a record started for them, so we note on their record that they are JW. A couple of these folks have come back in through our ER to ICU with blood orders and we notified the physican, documenting this notification, as to what the patient's previously stated wishes were. (We did not refuse to carry out the doc's order, we did not delay in getting product ready for transfusion and we would never refuse to provide any product the patient agrees to accept.) The patients were grateful for our concern for their values.

There are a number of cases where minor age children have been transfused contrary to their parents wishes. The physican(s) and/or hospitals have gone to court to get a judge's order to do so. The parents seem to lose most of the appeals they file to stop the transfusions (and not just for cases involving religious issues). If an adult is capable of giving informed consent and refuses, that's that. I know of a case where a patient died after refusing transfusions for a GI bleed. The patient was asked to sign a release very carefully drawn up specifically for her case. Her family saw the issue from her point of view, so no issues there with the potential of a law suit. I haven't seen anything about disputes where blood is transfused in a trauma situation, but it would be interesting to hear someone else's experiences.

There was a time - long ago - before fetalscreens, when our OB/GYNs wanted the antibody screen to see if they should give more RhoGAM post delivery. These were drawn 24 hours after the first dose was given. As I recall, approximately 20-30%, (rough, rough guestimate) of these patients got another RhoGAM because their screen was negative (tube testing, of course). A few even got a third dose before we got a positive screen (and they were usually larger size women). Anybody delivering twins automatically got 2 vials to start. We argued until we were blue in the face about the use of the screen for this purpose, but they had heard it at a conference - GOD had spoken! We started doing fetalscreens when the kits became available and reported them in parallel with the antibody screens. After about 18 months, it started to sink in with them that the fetalscreens were all negative. Imagine that! They asked for information about the fetalscreens (and maybe heard something more at a conference) and suddenly, no more antibody screens were ordered to determine RhoGAM dosage. So, in answer to your question finally, you can see a significant number of women with a negative antibody screen doing it the way your doc is asking you to do it - depending on your method. You may also see a 4+ reaction within a few hours post dose with gel. Maybe a little education by your medical director would be helpful (or not!). AMcCord

The lab manager has subscribed to this for continuing education/competency at my facility. He gets a report - I can't tell you if he pulls it up when he wants to or if it updates monthly or some other format - which details who has done which exercise and when. The report tells him what the inidividual scored, what the average score for everyone at this facility was and there is a comparison with what other facilities are scoring. He can print out a report for each tech to show them what is assigned to them and how they are doing. This report tells you what you have completed, what is started but not complete and what is finished (with your score). When you log on with your password, the exercises assigned to you show up in a list. You pick what you want to tackle that day and get started. Most of them have a review section, then a test section. You get immediate feedback with your answers both in the review and test section. You see your score when you finish. Then it reviews you with material which relates to what you goofed up. If you can't finish an exercise, it remembers where you were and you can resume where you left off at a later time. The exercises seem to be pretty thorough for the most part. They may include photos, graphs, tables, etc. He assigns section supervisors here all of the exercises:cries:and I have to say....I'm pretty lousy in Micro! Overall, I think it can be a useful tool. AMcCord

You are cutting out the middle man - yourself and all the extra steps it takes for ordering, checking out, etc etc - since Pixis will dispense on the patient floor. That = $$$ saved for your institution, which is always a good argument for anybody. It worked for us.

We sent all albumin to the pharmacy some years ago and haven't been sorry. It is dispensed through the Pixis system on the patient care areas. It saves us a lot of hassles and improves patient care by cutting down the time it takes for infusion to begin. Since we don't need a blood type, etc. there seemed no reason for Blood Bank to handle it. Pharmacy takes care of procurement, billing, etc. The lots and outdates are tracked by them just like they track any other medication. We do still handle RhoGAM - that I feel Blood Bank needs some control over to ensure that the patients who need it here, get it.