heathervaught

Our blood center uses the MDS Nordion Raycell for all of our irrdiation needs: http://www.mds.nordion.com/products/blood-research-irradiators-b.htm
I have never used a cesium irradiator, but the operation of the Raycell is simple -- place the blood products in the canister, place the canister in the irradiator, close the door of the irradiator, and press the start button. It takes about 6 minutes per cycle. We have dosemapping performed approximately every 6 months to verify adequate dose. In addition, each product is tagged with an indicator to show that it received an adequate dose.
I have attached a copy of our validation.
Raycell validation plan.DOC
Irrad worksheets.doc

All that I have seen break have "pancaked" when they hit the floor and broke at a seam.  Quite the mess.  Seems to happen once every few years where I've been. I learned quickly to juggle any dropped unit down my leg to break its fall.

Leukoreduction does not matter. Frozen plasma is considered an acellular product. Similar analogy for why frozen and then thawed plasma does not need to be irradiated for those individuals at risk for graft-vs-host disease.

Heck, with an 8.5 Hgb, I would try to avoid transfusion on this patient a little longer anyway.

I will try to answer this without completely boring everyone with the insanity that is RH genetics.
For a true weak D, the antigenic epitopes of the RhD protein are the same as those in a D-positive individual, they just have fewer of them so serologic testing comes up weak. RhIg actually does nothing for these women because they will never become immunized. You are on the right track about the "mosaic", now referred to as partial D. There are many genetic alterations that cause partial D and the RhD protein in these individuals can differ significantly from the "normal" protein. Actually, there are many genetic alterations for weak D as well, but I digress.
From what I have read, the mechanism by which RhIg prevents immunization isn't well understood, but the theory that it binds to the foreign RhD protein and blocks recognition by the mom's immune system in common. The wonderful thing about human sourced RhIg is that it is polyclonal and can therefore recognize the modified protein in partial D. It will, in theory, also recognize the normal parts of the protein, but this generally doesn't cause significant problems even in those with weak D. Studies with monoclonal RhIg have shown incomplete protection against immunization. I believe most transfusion services act conservatively and administer RhIg to all mom's with weakened reactions in serologic D typing tests, mainly because serology cannot differentiate between weak D and partial D. Literature suggests that RhIg need not be given to those where genetic testing has classified them as weak D types 1, 2 or 3.
I'm sorry if I have managed to confuse you with this quick and dirty explanation. You may find this paper helpful.
Flegel WA, Denomme GA, Yazer MH. On the complexity of D antigen typing: a handy decision tree in the age of molecular blood group diagnostics. Journal of obstetrics and gynaecology Canada. 2007;29(9):746-52

Have you redone the crossmatch with the transfused cells? Maybe the antibodies is against low incidence antigen not expressed on the screening cells?

If you are in the SBB program, I imagine you are with the Gulf Coast one, then you will do well on the exam. As for a research project, talk to your program director who can give you some ideas. Try to come up with something that would apply to your facility. Talk to your pathologist and see if he/she has any ideas that might help you. I know the program is not easy, but study hard. I did it 2 years ago and am so glad I did (even gladder that it is now done, lol). Good luck

We also have two different models of Sysmex instruments. What I found was that one consistently reported values significantly lower than the other. To minimize impact of one more variablilty in the process we have all of our pre-donation samples and product QC samples tested on the same model.... You may want to check the correlation of the two hematology instruments using platelet samples. A 7% disparity between instruments has a much bigger impact when you are testing levels at x10<11> vs. X10<3>. You might be surprised!

:bored:On 6/7/08, my 225 bed hospital was flooded. The lab was in the basement. The water spread from floor to ceiling and into the first floor(14 feet of water)! Information Services, Food Services, Elevator Services, Pharmacy, Electrical Services were also in the basement. The patients and personnel were all evacuated within 3 hours with the help of the National Guard. No one was injured. Needless to say the hospital was closed for 5 months. We lost EVERYTHING in the basement. It was later declared a 500 hundred year flood. The hospital is next to a very small creek.
The lab had an off-site blood drawing station where we resumed out patient services 2 days later. We sent the specimens to a reference lab. Within 2 weeks they moved in a mobile Emergency Room for which we purchased new lab equipment and provided basic services for these patients. We stocked 4 units of O Negative blood in a blood refrigerator in a house across the street where the Helicopter personnel lived.
Management personnel were housed in an airport hangar. Within a few weeks, we had new computers and began trying to think of everything we needed to replace. It was a huge task. I wished I had had a document listing all of our equipment, etc. I was greatful that our procedures and our personal hard drives were able to be restored on the computers.
It was a devasting experience, but due to a lot of hard work, 4000 construction workers, and FEMA we moved back in to a temporary lab in 5 months. The hospital was reopened. It was a great relief to the community since we are the only hospital within miles. 6 more months later, we moved into a new lab (on the first floor!!).
Lessons learned: I don't think you can fully prepare for such a disaster and our hospital and lab Disaster Manuals didn't work! We didn't have land line phones for days and computers for weeks. We even ran out of toilet paper in 2 days in the off-site location! We now have new disaster plans, but I have lost confidence. In hind sight, communication with personel was difficult. We set up a lab group email so we could at least communicate with them at home if they had computers. I now keep their phone numbers at home. Everyone remained employed in some capacity.
Positive aspects included that people from all departments learned to work together and there was good comradarie.
I hope that none of you ever have to experience anything like this.

And, as I always tell my staff when they ask me questions, "Whatever I don't know, I just make up!!!"
(I'm just kidding, OK?)

NO!!!

:no::no:

I saw a new admitting diagnosis Tuesday---"Sick Patient". Hmm, I wonder who would go to the ER if they weren't sick?! It did provide a nice laugh for us in the Blood Bank.

Rebecca, your father and I had some interesting debates on a number of issues on which we did not see quite eye to eye. I enjoyed his perspective and he kept me from getting to far out in left field, so to speak. His wit and wisdom will be missed by all in these forums.

http://hosting-tributes-24789.tributes.com/condolences/view_memories/89295193 My father passed away in an unfortunate mountain biking accident with my brother. Please post any stories if you have any. I would love to hear as much about my father as possible. He was a good man, a hard and dedicated worker, and the best dad I could have asked for.
Thanks, Rebecca Smrz

Although publication in the NEJM gives this article the veneer of credibility, there are a number of problems with this study. First, it is a retrospective study, so it does not have the power that a prospective randomized controlled trial would have (despite the authors' attempt to argue that their retrospective data was "prospectively" by clinicians carrying out patient care. Although the authors argue that the populations were matched, they simply were not. Here are the differences between the populations that by the authors own work are statistically significant:
Statistically Significant Differences in the New Blood vs. Old Blood Populations


Blood group (# of units/total # of units - %)53.1% of new blood units were type O, only 31.1% of old blood were type O 56% of old blood were type A, 37.9% new blood type A Blood group (# of patients/total # of patients - %)50.9% new blood patients type O, only 30.4 percent old blood type O 49.4 % old blood type A, 34.7% new blood type A Higher rate of abnormal left ventricular function in the old blood group (63.1 vs 57.9% Higher rate of mitral regurgitation for old blood (67.3 vs. 64.1%) Peripheral vascular disease higher in old blood patients (58.5 vs. 54.4%) Leukocyte reduction: significantly higher number of old blood patients receiving both leukoreduced and nonleukoreduced products (11.4 vs. 3.9) Larger body surface area in older blood patients #'s 3, 4 and 5 indicate a higher risk population than the "new blood" folks. The authors talk about ventilator time, but have made no adjustment for pre-existing lung function - these are elderly people - want to bet how many of those folks with peripheral vascular disease were/are smokers with less than optimal lung function? Take a look at Figure 1A. This is where "demonstrate" the two populations are the same with regard to # of units transfused. The scale on the Y axis is 0-30. Now look at figure 3 - the Kaplan Meier curve they use to show their "significant difference" between old and new blood folks. Looks like a big difference, right? Until you check out the scale, where the entire graph is a 15% spread (from 85-100%). So they've magnified a really small difference to make it seem big. Oh, and if you pull that same little trick on figure 1a, it shows the same "huge difference" in the two populations as they are claiming for fig 3.
NEJM did a big disservice in printing this article in this form. The most this article does is support the need for a randomized controlled prospective trial. We are all aware the storage lesion exists, but none of us know its true impact on patient outcome in cardiac patients or any other.
That said, it unfortunately was well publicized on a slow news day. "Old Blood Can Kill You" in our local rag - it almost made me bleed into my brain. Although some of you are struggling with your surgeons and clinicians, my greatest concern is what we will be hearing from patients and their families every time we transfuse them and they question how old the blood is. And should there be a bad outcome for any reason, well - welcome to litigation land, because surely it was the "bad old blood" that killed the 85 year-old 3 pack a day smoker with CHF, diabetes and metastatic cancer, right?

I would like to respond since I am a senior tech at the IRL who did the ID on the patient in question. Of course, we follow the AABB IRL guidelines when identifying a specificity. The patient in question also has anti-E, -S, -K and -Fya in addition to the –Cw, -V and –Dia mentioned previously. This patient has made all of the commonly encountered allo antibodies that we would expect with his phenotype. He has a history of GI bleeding and has had multiple episodes at various local hospitals dating back to 2005. We often fill his requirements from our Ro phenotyped inventory due to his antibody history. As can be assumed, most of our Ro donors are either African American or Hispanic and therefore it is not unlikely that the patient has been exposed to the V and Dia antigens. Since the patient does not require C negative units, exposure to the Cw antigen is also not unexpected. As we test this patient in the future, we will likely identify other antibodies to low incidence antigens as these happen to be on selected cell panels. I would imagine that other reference lab staff would agree with me that we do not identify these specificities as a whim. Once identified, we are faced with having to decide how to handle them every time we get new requests for red cells. Julie

Food for thought!
The CAP Transfusion Medicine checklist TRM.32250 indicates that patient records should be retained for 10 years. Are not these antigrams considered "patient records"? What else would they be? The only mention of a 5 year retention period concerns quality control and retyping of donor unit records.

Unresolved issue, how are others handling + sickle donors?
1. do you send notification letter, if so what do you say?
2. do you allow them to continue to donate?
3. if unit goes through filter and leukoreduces how can we be sure the wbcs are effectively removed (per literature) without counting each product?
4. do you put the donor on some sort of flag or surveillance in case they come back?
THANK YOU!

When I logged into Blood Bank Talk, the banner displayed "Hello sjlevine it appears that you have not posted on our forums in several weeks, why not take a few moments to ask a question, help provide a solution or just engage in a conversation with another member in any one of our forums?"
My response to this is that I would visit and post sooner if I did not have so much work to do, particularly in the area of ISBT 128.
I will say that what we have done so far has been a learning experience. We have instruments, such as the Abbott Commander, that will take ISBT 128 numbers, but leave them unprocessed, thus leaving it to us to process them before they go into our Blood Bank Information System. Abbott has no plans, they tell us, to make the commander ISBT 128 compliant, even though Anti-HTLV I/II and Anti-HIV assays are not yet licensed on the Prism.
Anyway, I came, I looked and I posted. And vented.
sjl:D

I looked at the Nordion very closely at the 2007 AABB Txpo in California. The suitability of the instrument really comes down to your volume. It is relatively large, as a current total volume of 1.5 Liters and a 5 minute cycle time. The instrument uses two X-Ray tubes (top and bottom) and the tubes are each warrantied for 2000 hours of service. The device needs a water feed on a dedicated cooling loop (per code for water cooled devices in our area). The device has a 3 to 5 minute warm up period from a cold start and is not intended for continuous use. So, you have a warrantied period of 24,000 cycles on the tubes but could/should see more. If you average two products per cycle, that is 48,000 products within the warranty period. Your mileage may vary.
Franklyn

How often do you need to replace the "bulb" on the x-ray type irradiator? We irradiate approx 1,000 products per month and when we replaced our irradiator a few years ago, our biomed department calculated out the cost & frequency of replacing the "bulb" and determined that it would be cost prohibitive for us to be able to keep an X-ray based machine running with our volume. Are any other large volume facilities using this type of irradiator?

We are also looking to replace our iradiator with an X-ray type, hopefully to coincide with a move to a new laboratory at the end of 2009. I fear we may be compelled to do it sooner, though, judging from the press. Besides Nordion, does anyone know of any other vendors? Nordion is great, but Canada is a long way from here and the PM/service calls are expensive, even if infrequent.

We've been using the Raycell for over 5 years. The cabinet is approximately 4X5X2 ft. It's lead lined and sits on casters. You need a water line, a drain, and 220 electrical line. The canister will hold two AS-1 RBC or several pheresis platelets. Our cycle is 5 min. The maintenence is minimal and dosimetry checks are not complicated. We have a radiation physicist check for leakage one a year. I think they're going for about $180K, but you'd need to check the current pricing with Nordion.

The Nuclear Regulatory Committee is rolling out in the near future even stricter security measures for Cesium 137 Blood Irradiators. The current security regulations are a bear to conform to, but the new regulations are even more onerous to conform to. My Radiation Safety Officer is pulling out his hair right now and with the recent press on the possibility that these irradiators are primary terroristic targets, having the most accessible source of dangerous radioactive material and the the extreme danger that the cesium 137 source material could cause if terrorists do obtain this source, he is recommending that we get rid of the cesium 137 blood irradiator ASAP.
He is actually seeing terrorists coming into our hospital (six terrorists to be exact), kicking down the door, shooting everyone in the room or anyone that responds, pulling the irradiator apart, breaking into the bottom of the lead barrier and taking the actual source out.
The article states that the Defense Science Board is recommending the removal as an overall strategy to reduce the threat to the united states from terroristic activities. It further states "Any one of these 1000 plus sources could shut down 25 square kilometers, anywhere in the United States, for 40 plus years". The article is "Terrorism: Hospitals a Hot Commodity" by Pamela Hess of the Associate Press, if anyone wants to read the whole article.
Is anyone else, who has a cesium 137 blood irradiator, also getting pressure to remove this irradiator or replace it with an x-ray blood irradiator or other equipment that can do the same thing? Does anyone know what companies have this x-ray equipment or equivalent device. What the price tag for anyone of these devices and the differences in actual use of these devices as compared the the cesium blood irradiator.
[Edit by site admin]
I have included the article in our files section.
A word of caution.
The NRC through, my local Department of Public Health, has contacted me regarding posts related to irradiators. I will monitor all posts closely, and will need to edit them if necessary.
Under no circumstances should you post any information related to your facility, the security of your irridiator, or irradiator security policies in general.
Thank you for your understanding.

Thanks to a fellow Hoosier!