GilTphoto

We also use different codes for passive and immune anti-D. If you have records of RhIG being given, and the anti-D reacts weakly (< 2+) in IAT only, we call it passively aquired anti-D. BUT, if it reacts at IS or 37C, or 3+ - 4+, then we titer it. If the titer is greater than 1:4, we call it immune anti-D. Passive anti-D rarely titers greater than 1:4.

We have had that happen twice this year.

Kleihauer/Betke does not detect Rh positive cells, it detects fetal cells and should not be used for this purpose. I can see giving RhIG for Rh positive platelet transfusions, but for RBC transfusions, giving RhIG is probably an act in futility. BTW, I heard insurance companies don't pay for RhIG given after Rh pos products (mentioned somewhere is this forum).

I had used Hemo-Temp II indicators back in the 80's, and they worked fine. I recently ordered them for the current hospital I work, and they don't seem as good as they used to be. The flower is very faint. We are using a water bath to activate. Has anyone compared the Hemo-Temp II to the Safe-T-Vue 10 indicators?

For small hospitals that pool and split about 10 times a year, the Digi-Trax software is just too expensive. We also use Sunquest, but haven't moved to Version 6.3 yet. Still using version 5.4. My schedule just hasn't found time to start validation, and I'm already working 10-12 hour days. Thank god our supplier won't be ready for ISBT 128 until August!

Julie, I don't know what the statistical incidence of Cw, Dia and V are in our Hispanic/Black population in S FL, but I thought each of these were about 1:1000. (I know that Dia is about 8% in Asian population, but in Hispanic, I have no clue). Wouldn't that make the odds of being exposed to all 3 low incidence antigens like 1 in a million? That is the sole reason I questioned the report. I also worked on this patient. I had 3 Dia positive cells from 3 different panels, but none that were negative for S, E, Fya, or K, so I couldn't prove or rule it out. Same with Cw, just couldn't rule out. Julie, I apologize for questioning your work on this patient. I think it's definately an interesting case. I saved the plasma from 5 tubes, to investigate more. After all the phenotyping we paid for on this patient, they never transfused him. This patient has been hospital hopping in S FL, which is never a good idea when you have all these antibodies. Gil

Not 2%, 2 grams Hgb. Since the literature says the average increase in Hgb from one unit is 1 gram, I question when the Hgb jumps more than 2 grams. Does anyone else monitor this for the blood usage review?

We just had a case a few weeks ago. History was O pos, currently B pos. The previous record was from 2001. When we went back to redraw the patient, the patient questioned why? The phlebotomist told her the blood type didn't compare with her record from 2001. The patient replied, she has never been in this hospital before, but did have her wallet stolen in 2001. The person who stole her wallet, used her identity to get surgery done.

What is the policy at your hospital for discarding blood from CVP lines prior to specimen collection. How many mL's? Some hospitals do 5mL, some do 10mL. Does anyone have a reference? Thanks Gil

We just had a patient come in with a previously identified E, K, and cold auto. Now there is something else there we couldn't identify. The reference lab reported Cw, Di(a), V, and S. I just don't believe it. Cw, Di(a), and V are extremely low incidence antigens. What is the statistical possibility that a single patient can be exposed to all 3 of these antigens with just a few transfusions? I voiced my concern to the Reference Lab Manager, but they stuck by their report.

The nursing policy for discarding from CVP lines is 10mL, but every nurse I've spoken to, only discards 5mL. I think this is the problem. We documented 5 cases in March. All had specimens drawn from CVP's. We brought it up with the CNO. Time will see if anything changes!

The average increase in Hgb after 1 unit of packed cells, is supposed to be 1 gram. Does anyone monitor when an unusual increase in Hgb after transfusion occurs? When the pretransfusion Hgb is 7 and 2 units are given and the Hgb jumps to 13, something is wrong. I think it's attributed to specimens drawn from CVP lines from nurses. They are not discarding enough blood, causing the pretransfusion Hgb to be falsely low. I'm thinking of establishing criteria of >2 grams per unit as the flag for review. Does this sound about right? Anyone do something similar? Thanks, Gil

Ditto!

Therapeutic phlebotomies are medical procedures that should not be done by phlebotomists or med techs. This is not like drawing a unit for donation on a healthy person. These patients are sick and have other complications and expose the hospital to a huge risk if not done by someone qualified. In our hospital, the house physician used to do it, but they are not trained and do not have the right equipment. If you do not have a scale to know when you have drawn off the requested number of mLs, you may get too little or too much. We have a contract with a mobile apheresis service that does it. It removes the liability from us, from any complications that may arise. Gil

Don't forget about checking the rotator RPM's on each day of use. We have the Helmer Platelet Incubator and the RPM's must be 68 +/- 10%. We only have a bottle for temp checks. Never saw any requirement for placing a thermometer in a platelet bag. Gil

How are you using a single unit until expiration? It's my understanding that red cells for newborns must be less than 7 days old because of the red cell leakage of potassium. After 7 days, the potassium level is too high for newborns to handle and could cause cardiac problems. Are you washing these aliquots before transfusion? Gil

We check our platelets with a urine dipstick and they all have a pH of 7-8 and a glucose of 500-1000.

The phlebotomists complained at first, but realized it's easier than getting another sample. The pathologist and myself brought up the plan to our Chief Nursing Officer, to get her OK. The policy was incorporated into the nursing manual and we gave an inservice to the nurses, so they would know we were going to request their help. Yes, some are being fudged. The nurse signs the form without looking at the specimen. This is obvious when something is incorrect. The nurses and phlebotomists have been informed that this is serious business. If a patient is transfused the wrong blood because of misidentification, both people who signed that form will be fired. When mistakes are found, I go back to the nurse and explain the implications of not checking. Most errors come from the nurse collected samples, but they are decreasing. Most errors are minor spelling errors on the typnex label, so far never that the wrong patient was drawn. I'm not sure how to paste the form here. Can it be done? If not, send me your email in a private post, and I'll send it. Gil

John, Of course we back up a report of passive anti-D by investigating whether the patient actually got ante-partum RhIG at another facility, if not in our records. As far as the baby's results, even if the baby's DAT is positive and you elute anti-D, the doctor won't care as long as the bilirubin stays low. We had a mother with an anti-D with a titer of 256, and an anti-C with a titer of 128. Both antibodies were eluted from the baby's cells. The baby's first total bilirubin was 3.2. The next day 6.5, the day after 14.9. Then it started going down and the baby was discharged. Gil

Repeating the ABO on new patient's is a lot of extra work and extra cost. I chose to use a Phlebotomist Witness Statement, where the phlebotomist gets a nurse to witness the phlebotomy and both check the ID of the patient and the labeling of the specimen. The form much be signed by 2 individuals. Two signatures is a lot easier, faster and cheaper than two ABO's. We had our CAP/AABB inspection in October and the inspector liked the procedure. I'm writing this from home, but if you'd like a copy of the form, I can send it tomorrow. Gil

We only do a titer of anti-D if it reacts stronger than 2+, or reacts in a phase other than IAT (IS or 37C). If the titer is less than 1:4 it's passive anti-D. Gil

the problem isn't that a lot of rouleaux is being seen, it's that it's being called rouleaux when it's really a cold auto. Real rouleaux doesn't go away when you warm it!

Cultures should be done with blood culture bottles. The volume is whatever you can get out of the pigtails (which is less than volume for blood cultures)

One reading at IAT, 60 minutes, no LISS. The technical manual also states to read the endpoint as the last tube showing a 1+ macroscopic reaction. This is not always the case. There are several reasons for performing titers. 1. Pregnant mother with significant antibody. Read macro only 2. To tell whether an anti-D is passively acquired due to RhIG or immune. <1:4 is RhIG. read microscopically - last positive. Only done if reaction >2+ or reactive in a phase other than IAT (IS or 37C) 3. To tell whether a high incidence weakly reactive antibody is a HTLA antibody (>64) read microscopically - last positive. 4. Titers used to be performed on cold agglutinins for mycoplasma pneumonia before better tests were available. Titers >1000 usually indicate CAD (Cold Agglutinin Disease or CHD). DAT is normally positive with C3 and it can cause a hemolytic anemia. A blood warmer is only recommended for cold autos when they are this strong and don't prewarm away. Gil

I've never heard that. Why would EDTA tubes have higher protein? That's what we use: pink tops. Rouleaux should be rare. Gil