GilTphoto

This is where the use of a secondary BB armband and label comes in handy. We use Typenex armbands. If using this secondary number that's checked before transfusion, the armband number wouldn't match, so the transfusion wouldn't be started.. The armband number from spec A would be put on the compatibility slip for patient B. When a nurse comes to pick up blood, they must write the armband number on a copy of the signed consent with a copy of the order to transfuse. We compare the number before issuing.

We only retest if something different is detected, such as an unexpected screening cell or incompatible crossmatch with antigen negative blood from previously identified antibodies.

Our experience with neonatal platelet transfusion is rare. The couple of times I've seen, the order was a one time transfusion (maybe they transferred the baby to a REAL hospital) <g>

I can't see wasting a Pheresis for a neonate. The average volume transfused is about 10 mLs. We only order a single donor Platelet which is only 50 mLs. There is a BIG cost difference. Our Pheresis costs $590, while a single platelet is only $40. We issue the complete unit and the nurse pulls off however many mLs they need, then discards the remainer of the unit.

We only do them post-partum. If a pregnant woman falls or is bleeding, we give 1 RhIG, but don't do a KB. Does anyone have a reference for the need for doing them ante-partum?

We already do. Last year total was $61,000 for a total of 477 inappropriate and wasted units.

Sounds like my hospital. I work in a third world country (Miami, FL). Most of the doctors did not go to med school in the USA. No one speaks English here. They do whatever they want and waste many FFP and PLT's. We had 477 inappropriate transfusions last year (about 11%). Inappropriate FFP transfusions in February was 56%. They transfuse 1-2 units prior to procedures if the PT ot PTT is 0.1 out of normal range. PLT's are transfused if < 100. They have no idea how many units to order either and always over order. They do not follow up with post transfusion testing (20%). 165 patients received RBC's with Hgb >9. We also discarded 51 units of FFP thawed but not used. Our Pathologist does nothing to stop it. The last Medical Exec Comm, our Lab Manager was given 30 seconds to discuss 40 pages of reports. I'm wasting my time creating these reports, but can't get out of them.

we also use zip-lock bags

Our Pharmacy orders the RhIG for us and receives the revenue. We get the entire inventory about 20 vials at a time. We do the storing and dispensing. Our RhIG, Fetal Screen, K/B procedures had to be updated to Pharmacy's liking, but we still control it, they just oversee it. The Pharmacy Director found the doctors were ordering "Give 300 ug of RhIG" and had them change order to not mention the dosage as it might be different due to FMH. "Give RhIG as per lab protocol"

Who presents the statistics at the Transfusion Review committee? After being promoted to BB Supervisor, it was 6 months before getting caught up with Transfusion review. There were 47 pages of reports. I was given 5 minutes to discuss them. Because I objected and continued to talk, the COO told the Lab Manager, he only wanted him to present the statistics and not me, from now on. I have tried talking to the COO, but he insists he only wants department managers at that meeting. I'm not even allowed to attend. This is not a separate Transfusion Review Committee, only a part of the Medical Executive Committee. I recommended a separate committee for transfusion, but no one is interested.

We actually had an interesting case related to this poll. A pregnant mother can in at term with an anti-D reacting 2+ at IAT and one cell that reacted at 37C. Titer was 1:16 score=43. She had received RhIG at 5 and 7 months. This was her 3rd preg. Her baby had a positive DAT with anti-D in the eluate. Bilirubin rose from 3 to 9, over 3 days, then decreased. The mother also had a positive Fetal Screen and K/B. ratio=0.0043. Just in case the high titer was due to receiving 2 doses of RhIG, we played it safe and gave her an additional 2 doses. Just wondering what everyone else might have done. Would anyone call it an immune anti-D and not give RhIG?

tube method

If the anti-D is < 2+ at IAT only and the patient has received RhIG, we report passive. If it reacts at IS or 37C, or is 3+ or stronger, we titer. <= 1:4 - we report passive anti-D > 1:4 - we report immune anti-D

RULE 1: Always use the freshest panel if more than 1 lot # available. Antigens deteriorate with storage. RULE 2: Always incubate panels 30-60 minutes for strongest reactions. We do our panels at IS, 15' RT, 30' 37C, and IAT with IgG. If a cold antibody is suspected, avoid using LISS, PEG, N-Hance, because they all enhance cold antibodies and may interfere with identifying warm antibodies if the colds react at IAT. Do a strict prewarm IAT phase only for eliminating interference from colds. If you have both a cold auto and Le(a), I bet the patient is an A1 or A1B. The cold auto is probably an anti-IH or anti-H, that reacts stronger with O cells, then with A or B cells. Lewis antibodies are usually found in patients who are negative for both Le(a) and Le(, and they are often found transient in obstetric patients. In patient's with anti-E, you should also consider if they are c neg, as R1R1 patients with anti-E, are usually exposed to c as well, and the anti-c may be undetectable. In this case only, we give E=c= blood. There is a paragraph in the technical manual that discusses this instance - Rh chapter, Con-commitant antibodies.

While we have a pneumatic tube system, we don't send blood through it. A nurse has to physically come to the blood bank with a signed copy of the informed consent with the blood bank armband number written on it. We then record the unit number, product type, date and time issued on the form, then do a clerical check with the nurse: 1. Name and billing # on form, match compat label 2. Patient ABO/Rh and unit ABO/Rh 3. unit # on compat label match unit label 4. exp date on compat label match unit label 5. BB armband # they wrote on form, matches the # we have on label We then use this form to manually charge for the product at the end of the shift. We would like to get away from using the consent, as we have to statistically analyze what percentage are signed by the doctor (poor - only 20-25%) and what doctors aren't signing. The committee always wants a plan to improve the signature rate, but nothing seems to work! Too much work for nothing! I would like to use a form where they check off justification for transfusion, but our pathologist doesn't want to rock the boat. I wouldn't feel comfortable with no pick-up slip at all.

Passively acquired anti-D due to RhIG is usually only weakly reactive at IAT. If the anti-D shows up at IS or 37C incubation, or is 3-4+ at IAT, then we titer to distinguish between immune and passively acquired anti-D. anti-D due to RhIG usually titers less than 1:4. Anything greater than that, indicates an active immune response. As others have stated, titering other antibodies post-partum, is of no benefit. Only rising serial titers during pregnancy can alert the doctor that the baby is antigen positive and at risk of HDN. We automatically reflex the titer. No order is necessary.

This is what we do. The purpose in testing is to ensure any serum antibody has been removed before adding the eluting solution. If it's positive, continue to wash the cells.

We test every cord blood for ABO/Rh and DAT (IgG only). If the mother has a significant antibody capable of HDN, we antigen type the baby and do an elution if indicated. Our cord bloods come with a label from the mother with a cord blood sticker (if twins, then A and . When the cord specimen is collected, the newborn hasn't been registered yet, so labels for the baby aren't available when the specimen has to be labeled. The specimen is sent with a copy of the order for the baby with their ID numbers, linking them to the right mother. Any discrepancy, we collect a heel stick. To avoid false positive reactions from whartons jelly, we take 6 drops of cord blood , wash 4x in cell washer and make a cell suspension with that (a very small one) Perform -A, -B, -D with 1 drop of suspension. Place 1 drop cell suspension in IgG tube, and wash an additional 3x, add coombs, spin ABO discrepancies with cord blood specimens can also be caused by a significant FMH. We have seen weak reactions with monoclonal anti-A on at least 3-4 babies a year, and suspect an A subgroup, but cannot confirm with A1 Lectin, as it's not recommended for use on newborns. The A antigen is not fully developed yet. Incubate 10-15 minutes at room temp and recheck. Check the mother for subgroup of A. Every time it happened to us, that was the case. Mother was A2 or lower.

I'm really surprised that so many do automatic eluates! We only do them if the patient has been transfused within the past 3 months, or is pregnant. I can understand the rationale in shortening the 3 month period, since after a few weeks the antibody response should be strong enough to be detected in the plasma. The only purpose in doing a DAT, is as an indicator of a hemolytic process going on. What information can be gotten from the elution if not transfused recently? Positive DAT can be caused by: 1. Antibody response to transfusion or pregnancy. An antibody may be coating transfused cells and be undetectable in the serum. 2. Passively aquired antibody Newborns: (HDN). We only do elutions on newborns if the mother has a significant antibody capable of HDN and the baby is antigen positive. We don't do elutions when the positive DAT is likely to be ABO related (O mother has an A or B baby). In both cases, the doctor only has to monitor the bilirubin, to see whether exchange transfusion is indicated, or more time under the bili light. Adults: If the patient has been transfused blood other than type specific such as an AB patient receiving many A cells or platelets, and the elution using O cells is negative (Gamma Elu-kit), a Lui-Freeze/Thaw elution should be done using A + B cells, to rule out anti-B (or anti-A if B cells were given). While anti-A,B passively acquired this way, causes a positiver DAT, it rarely causes a hemolytic anemia. 3. Drug Induced - A complete drug history should be obtained. Drugs taken within the past 3 months should be considered. While many drugs cause a positive DAT, only a few cause a hemolytic anemia. The eluate may be all positive, but is usually all negative. While elutions can be performed with drug coated cells, no useful information is obtained by doing the elution. If the doctor suspects a drug induced hemolytic anemia, the patient will respond to elimination of the drug, or sometimes reduction in dosage. 4. AIHA (Auto-immune hemolytic anemia - usually the panel is all positive too. The eluate will also be all positive. Could be warm, cold or a mixture of both. No useful info is obtained from this eluate either. Adsorptions have to be done to rule out underlying significant antibodies. Other indicators of hemolytic anemia should also be tested including Hgb, LDH, K, haptoglobin, immunoglobulins, etc. It WARM ANTIBODY 1. Idiopathic 2. Systemic Lupus erythematosis 3. Evan's syndrome (anti-platelet and other hemolytic antibodies) 4. Chronic lymphocytic anemia 5. Drugs (methyldopa) COLD ANTIBODY 1. Idiopathic cold agglutinin (or hemagglutinin) disease (CAD or CHD) - Autoanti-I that does not prewarm away easily (without cold absorption) and has a titer >1000. Would recommend a blood warmer in this case only! (not for the routine cold autos that prewarm away). Complement is positive. 2. Infectious mononucleosis - usually an autoanti-i can be demonstrated in the serum (stronger with cord cells, than adult cells). 3. Paroxysmal cold hemaglobinuria PCH - (rare) usually seen in children. Complement is positive. Serum contains an anti-P (not P1) a bi-phasic hemolysin demonstrated by the Donath/Landsteiner test. 4. Lymphoma Diagnosis related positive DAT Several diagnosis' have been associated with a positive DAT: RETICULOENDOTHELIAL NEOPLASMS 1. Chronic lymphocytic anemia 2. Hodgkin's Disease 3. Non-Hodgkin's lymphoma 4. Thymomas 5. Multiple Myeloma 6. Waldenstrom's macroglobulinemia 7. LIver Disease COLLAGEN DISEASES 8. Systemic Lupus erythematosis 9. Scleroderma 10. Rheumatoid Arthritis INFECTIOUS DISEASES 11. Childhood viral syndromes 12. Maleria 13. Mycoplasma pneumonia infection 14. Infectious mononucleosis IMMUNOLOGIC 15. Hypogammaglobulinemia 16. Dysglobulinemias 17. Immune deficiency syndromes GASTROINTESTINAL DISEASE 18. Ulcerative colitis BENIGN TUMORS 19. Ovarian dermoid cyst POSITIVE DAT - Cause unknown - As many as 10% of hospital patient's may have a positive DAT with no known factors, and without a hemolytic anemia. As far as waiting for the doctors to order an eluate, I think you'll be waiting a long time! I don't think most of them know what it is. I've never had a doctor order one in my 33 years doing lab. We add the order ourselves when it's indicated

Also try Advance for Medical Laboratory Professionals http://laboratorian.advanceweb.com/

While our policy is that blood must be < 7 days old, our neonatal doctor insists on blood < 5 days old. If it's day 6 or day 7, he won't accept it. Should we change our policy to accommodate him? Is there any reference for < 5? Only references I can find indicate < 7 because of potassium.

This is what we do.

At my hospital they usually only give 10 mL of PLT's to newborns at a time. I can't see wasting a PLT pheresis for a baby. A single donor platelet unit of 50 mL should be easier to find that is ABO compatible. I wouldn't worry about the Rh, as their immune system is unlikely to respond to the D antigen.

Blood warmers are recommended for rapid infusion of > 100 mL /minute and cold agglutinin disease. Cold agglutinins that fall into this category: 1. Do not prewarm away. You may need to do multiple cold absorptions and prewarm before getting the crossmatch compatible at IAT. 2. Have a titer > 1000 3. Cause a hemolytic anemia. DAT will be positive for complement. We have 4 blood warmers in our hospital. Up until now, our Bio-Med dept has only been doing an electrical safety check on them. Anyone have a procedure to share for checking the temp and alarm, as required by JCAHO. see requirement below. Blood Warmers - Alarm Check Documentation Q: Is Pass/Fail documentation acceptable for recording blood warmer alarm checks? A: No. While Pass/Fail documentation is commonly used for other biomedical equipment, it is not acceptable for blood warmer alarm checks. As required by standard EC.6.20 in the Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing, the actual temperature of the plates or effluent at which the alarm sounds should be recorded. here is the link: http://www.jointcommission.org/AccreditationPrograms/LaboratoryServices/Standards/FAQs/Management+Lab+Env++/Planning+and+Implementation+Activities/blood_warmers.htm

It's been 6 months and no one has an answer for this question? If we charge for the full unit when only giving 1/4, what happens if another baby gets one of the other 1/4's? Thanks