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Posts posted by GilTphoto
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Our hospital has never given out the 50 dose for abortion/miscarriage <12 weeks. Our ER doctor wants to know why.
We only use the 300 dose. Not sure of the original reason for this since taking over, so don't know what to answer.
We only issue about 10-15 RhIG/month. 90% post partum, 10% for abortion/miscarriage or vaginally bleeding during pregnancy.
Could it be because we wouldn't use enough of the mini dose to stock it and it would outdate?
Any other valid reason for only using the 300 full dose?
Thanks,
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We only split about 10 units a year. We split them into 4 bags, but 98% of the time, only issue 1 and throw out the remaining 3. We charge for the full unit, but no splitting fee. If a second bag is issued, we credit the second charge.
Don't know if this is right, but was the only way to recover our costs.
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I have no experience with Softbank, but just switched to Cerner a week ago, from Sunquest. Cerner is a piece of s***. The workload has increased fourfold. Too many unnecessary steps. The lab portion of Cerner called Pathnet, I have renamed Pathetic Net.
We were forced to change due to a corporate change in systems, and are unable to customize to our needs due to corporate Clinical Lab Standards team. Some desk jockies have decided how things should be. For instance:
1. No more test bundling, so no Type and Screen or Type and Cross. Tests have to be ordered individually. Nurses have to order ABO/Rh, Antibody Screen and Red Cell Product (Blood Bank has to order the crossmatch).
2. We use a 2 cell screen at 2 phases (37, IAT), but must use a screen with 3 cells at 3 phases (report not tested on cells and phases we don't do). We must also select method (tube, gel) when we only use tube. This has caused a increase from 7 keystrokes in Sunquest, to 28 keystokes for negatives and 33 keystrokes for positives in Cerner.
3. All positives generate failures where we must answer: Pattern match not found, Do you want to change results: NO, Override? YES, then select a reason: POSITIVE TEST RESULT. This is just nonsense.
4. All crossmatches stay pending for the 3 days the specimen is good for, so when you print a pending, you have no idea what is done and what isn't.
5. Can't see the entire ABO/Rh result fields on the screen at the same time. Requires scrolling left and right
I would rather go back to paper, than use this system!
For all the Cerner users that will say the program can be custom tailored, it isn't so in our case due to Corporate standards.
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At our hospital, we never get workups on mothers during pregnancy, and only see them when they come in to deliver.
A mother with an anti-D (titer=256) and anti-C (titer=128) delivered a baby who was positive for both antigens, but the bilirubin never got higher than 8.
Bilirubin was 3 at birth, 5 on day one, 8 on day two, then started dropping on day 3. The baby was discharged.
In the 8 years I have worked here, we have had many mothers with significant antibodies, but not one required anymore intervention other than time under the bili light.
So it doesn't really seem that you can correlate titer with outcome of the baby.
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We are a 200 bed hospital. Haven't seen an autologous unit in 4 years.
2 directed in 4 years
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You should not report a positive fetal screen on these patients since the test is inappropriate. Your policy/procedure should include that when a macroscopic result occurs you perform a weak D test and a specific test for fetal hgb, either by flow cytometry or a Kleihauer-Betke stain. If the K-B indicated more than one vial of RhIg I provide the amount indicated plus one vial. Just as an aside to the K-B, if you have pt with a persistance of fetal hbg (for whatever reason) it is prudent to perform a baseline K-B early in the pregnancy so that if a K-B is done later you can account for the % of maternal cells that test positive.
page 631, 16 ed Technical Manual states:
mother's positive for weak D's are not candidates for RhIG
We are currently in the dilema with being required by corporate desision, to no longer perform weak D testing (except for infants) starting with our new computer system
We currently perform weak D on everyone, and report as Rh positive if weak D pos. Fetal Screen=Not indicated, RhIG=not indicated
But the Rh Chapter says, weak D testing is not necessary in recipients.
So there is the conflict!
As a blood recipient we can call her Rh Negative, but as a pregnant mother, she should be considered Rh Positive for the purposes of RhIG.
They said we can report the weak D test, but can't call the patient Rh Positive, since the computer doesn't consider the weak D in the determination of the Rh.
Can't even override it
I guess I'm old school and don't want to let go of the weak D test. We have had a serious shortage of Rh negative blood, so would prefer to save it for true Rh negatives.
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I am in agreement with David, we wait until the morning H&H to collect the fetalscreen, and YES I have seen positive FMH with the way we draw them, so GiLTphoto your statement is incorrect that we will NEVER find a FMH with the morning draw.
OK, I'm sorry! Didn't mean never.
But there is the possibility of missing some, the longer the wait in collecting the post partum sample.
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Technical Manual says, preferably within 1 hour of delivery. Our phlebotomists draw the post partum specimen and pick up the cord blood at the same time.
The mother just gave birth, so you really don't have to worry about waking her, if it is drawn within 1 hour.
Some will be drawn for nothing if the baby is Rh negative, but we still report on the RhIG request: mom's ABO/Rh, baby's ABO/Rh, Fetal Screen=Not Indicated, RhIG Interpretation=RhIG is not indicated
Those who wait until morning will never find a FMH. Both the ante-partum RhIG and the ABO incompatible antibodies from the mother, will usually destroy most of the babies cells within a few hours if not collected early.
If your lab can say they haven't seen a positive Fetal Screen in over 10 years, that may be why!
We used to drawn next day, but we changed that.
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Two things:
1.Have you tried incubating longer?
2. How long do you spin for?
The results of our Serological Centrifuge Calibration always indicates that 20 seconds is optimal....... but....
There seem to be several reagents that don't work well at that time.
I believe the best time is 15 seconds (the default for the Immufuge), regardless of the silly Sero Cent Cal procedure we have to do yearly.
My night shift tech always reports 1+ for K+ control spun at 20 seconds.
I get 3-4+ when spun at 15 seconds. I also find Anti-A is hard to shake off at 20 seconds, amoung others.
So what to do? Somehow make 15 seconds work, the next time the Serological Centrifuge Calibration procedure is done?
If the centrifuge is the same, the rotor and tubes are the same, the RPM is the same, reagents the same, so how could the time vary?
The procedure is such a pain!
First dilute an ABO antibody to a magical 1+, with 6% Albumin (that you have to dilute from 22%)
and an Anti-D to the magical 1+
Years ago, we diluted Polyspecific antisera, but now with Monoclonal, the titer is just too high (512, >1000)
It's better to dilute a patient's plasma, so the titer isn't so high.
THe only thing is,...... the results don't resemble reality!
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http://www.pall.com/medical_52920.asp
We get Frozen pools of 5 units from Community Blood Center of Florida
they expire 6 hours after thawing as opposed to 4 hours after pooling in an open system.
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Had an interesting case today.
A 41 y/o male was admitted with an 8.3 Hgb. Diagnosis: weakness, R/O Guillain Barr Syndrome.
Patient has never been transfused.
Patient typed as A pos and appeared to have an Anti-A1. (1+ A1 cell at I.S.)
Did Anti-A1 Lectin to check for subgroup, but got 4+, so patient IS an A1 and not a subgroup.
Next did a short cold panel at both I.S. and 15 min RT
Cell___________IS_____ RT
SC I (O cell)___ 0______ w+
SC II(O cell) ___0______ w+
O cord________ 1+_____ 1+
Auto Control ___3+_____ 3+
A1 cell ________1+_____ 3+
A2 cell ________w+____ w+
Patient's antibody screen was negative at 37 and IAT.
Patient's DAT was w+ with both Poly and IgG (C3 neg)
Performed Elution by 2 methods:
Gamma Elu-Kit - neg with all O cells
Lui Freeze/Thaw - neg with O cells, 2+ A1 cells, neg A2 cells, w+ B cells
I have never heard of an autoanti-A1, but that is what this looks like to me.
Does this sound right? Is there anything else I could do?
He already got 2 A pos units last night, but I think for future transfusions should get A2 and not type O, because of giving him more anti-A in the residual plasma.
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I agree with David.
It's beyond the resources of most hospital transfusion services to workup WAA, unless the patient has not been transfused recently.
In that case, you can just do an auto-adsorption using the WARM kit, treat cells with Gamma-Quin so they can be phenotyped, do an elution, then issue phenotype specific blood.
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We are not as picky with the temp of FFP.
If issued shortly after thawing, coolers will never get the FFP down to storage temp of 1-6.
Coolers usually just maintain temp, not cool.
The fact that it expires in 24 hours anyway, we accept it back into inventory at any temp (<37)
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We do them on all cord bloods. The reason is because there be a low incidence antibody that we did not detect on the mother.
The doctors have gotten into trouble for discharging the babies too soon, that have complications. It usually takes a few days for the bilirubin to rise, so they could miss a potential problem.
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I'm also in the testing phase with Cerner Millenium Pathetic Net. Changing from Sunquest. We are due to 'Go Live' on Oct 4th.
I absolutely hate this program!
What's with all the left and right scrolling? I can't even see the entire ABO & Rh on the screen without scrolling.
Everything is about 4-5 times more keystrokes than Sunquest.
We use a 2 cell screen at 2 phases (37,IAT), but was told I have to deal with a 3 cell screen at 3 phases (IS, 37, IAT) and can just report NT (not tested) for what we don't use. To report the Antibody Screen: Sunquest=7 keystrokes, Pathetic Net=28 keystrokes for Negative, about 40 for Positives!
I need triple the staff to handle the workload with this program!
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our current process is being critiqued in detail and mercilessly by "others" (Not Blood Bankers!) and I need to know where to give and take in my position.
Thank you!
Do you work for TENET? Our process is about to change because of switching to Cerner Millenium. We are only 3 months from 'Go Live' and haven't a clue yet!
I hadn't seen this post yet, so I discussed this further in the thread on Rhophylac vs Rhogam.
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We have been using Rhophylac for >10 years. Our Pharmacy orders it and gets the revenue, but the entire supply is stocked and issued by the Blood Bank.
This is about to change. Our hospital corporation (TENET) is requiring that Pharmacy issue it. The change will occur with a massive number of hospitals switching to Cerner Millenium software. We have no idea what the process will be, and we 'Go Live' in October.
Anyone using Cerner and have a process for RhIG they would like to share?
Currently we use Sunquest and have 3 different orders for RhIG, but TENET is no longer allowing test bundling.
I'm afraid that there will only be an order for RhIG product, and the Blood Bank will have to order the appropriate tests.
RHIG-OP (for all antepartum reasons) includes:
ABO/Rh
Antibody Screen
RhIG Interpretation (RhiG indicated or not indicated)
Allocate and issue product
RHIG-AB (fetal demise - abortion or miscarriage) includes:
ABO/Rh
Antibody Screen
Fetal Screen - if needed
RhIG Interpretation (RhiG indicated or not indicated)
Allocate and issue product
Women in Labor are Typed and Screened upon admission
RHIG (post partum) includes:
Mother's ABO/Rh (we perform a weak D as a check for FMH - backup for FS)
Baby's ABO/Rh
Fetal Screen
RhIG Interpretation (RhiG indicated or not indicated)
Allocate and issue product
How does everyone else handle requests? Thanks
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We routinely hand out 2 FFP at a time. They can transfuse both together through a Y tubing filter. One on each side.
Since FFP and Platelets can be transfused as fast as the patient can tolerate the volume, 2 FFP and 2 PLT can be transfused within 1 hour.
We would discourage 2 & 2 though.
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the rouleaux seems to get stronger if the plasma is cold
It's not rouleaux. It's a cold antibody. Very weak cold antibodies can look like rouleaux. Rouleaux does not go away if warmed.
Rouleaux is also a RARE condition seen in patient's with protein abnormalities such as Multiple Myeloma.
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1-2% is too high. At 8000 units/year, that's 80-160 units/year.
Your inventory levels must be too high.
We transfuse about 2700 RBC's/year and we are not a trauma center
Our inventory levels are:
15-20 O pos
15-20 A pos
2-4 B pos
4-6 A neg
4-6 O neg
We never stock B neg, AB pos, or AB neg
Our outdate rate is 0-2 units/year
and we almost never return any blood
what we order, we use!
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CAP requires an alternate assessment for Cold Agg Screen/Titer since there is no survey available.
How does anyone do this?
Thanks,
Gil
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We currently test all cord bloods for ABO/Rh & DAT.
low incidence antibodies not detected in the mother would be detected by the DAT.
(I also work for a "For Profit" hospital)
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Have you considered HTLA?
most cells weakly reactive at IAT and ruled out most significant antibodies by phenotyping. Is that correct?
Sounds like it's time to do a titer.
>=64, then it would be HTLA
Matching the pattern for e could just be coincidence, as the patient is e+
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By the way.......
What's the difference between an oral and rectal thermometer?
.................... the taste! <g>
Rare Antisera
in Accrediting Agencies
Posted
Not really by much. I believe HB is only 3mL instead of other company's 5 mL bottle.
For those uncomfortable with using expired antisera, you can mass screen with expired stuff, and retest negatives with in-date antisera.