L106

I agree that we should head this way, and obviously OB/Gyn physicians need more education on this issue. Most of them use other laboratories for their prenatal testing, and then when the patients arrive here to deliver, we get different results from the other Laboratory and then we are recommending RhIg based on weak D results (or not, based on our results with our methodology) and it is not taken very well.
I think the problem for us is that we do not have molecular testing available, so we send our samples out to the reference lab for Rh genotype testing. The results do not come back for 72 hours, so we are still giving the RhIg as the results are still pending. It will help for future pregnancies though, as long as the mom comes back to this hospital.

Now, that's a great place to start such a registry.  I really like that idea, but we would probably be interested in only checking patients with antibody problems.  In our geographical area, there are only two blood suppliers, so it would be fairly easy to check with both of them.
 
Donna

Yes, I have also started using it; unfortunately the only indication is emergency use (for initial emergency release or for the first two units for an MTP). There are studies that show that on day 15, about 50% of the clotting factors are diminished so you should not be using this for your routine plasma orders for patients who need correction of clotting factor deficiencies (including Warfarin use).
It's wonderful for MTPs though. The docs love that we bring it right away. Then we start thawing FFP for the rest of the MTP.

I would agree that for patients this is overkill.  If they are SO weak that they don't come up in gel (and I can only talk for the Biorad cards but they can usually detect down to about 600 D-sites per cell - and the anti-D that you are using, Yorkshire exile, will go down even further) then I would not want to transfuse D+ anyway. What would you actually do with the result?? For cord bloods, well - is a cord blood with so few D sites likely to immunise a Dneg mum?  Donors is another question altogether.  I can well see that soon donors will be fully genotyped and then D will just be another antigen amongst many.  Currently though, there are papers that showed that a number of Del donors was being missed each year.  I also believe that Switzerland, who has been routinely typing their donors for about 2 years, have also found a couple.  Very interesting, academically, but it has pushed up the price of a unit of blood quite a bit and there's no actual evidence that they have actually immunised anyone, as far as I know.  I just get a bit upset sometimes when we in the developed world go to extraordinary lengths to maybe reduce the already negligible risk down further when many countries in the developing world don't have the resources to do more than an ABD slide - if they have the blood in the first place.

Congratulations, Terri!

There is a short, but very interesting case report in Transfusion that may be of interest to members, especially those using solid phase technology.  It is:
 
Irani MS, Figueroa D, Savage G.  Acute hemolytic transfusion reaction due to anti-Leb.  Transfusion 2015; 55: 2486-2488.
 
There are lessons to be learned, particularly the need to resolve ABO typing discrepancies prior to a transfusion.
 
I hope you enjoy it.
 
       

I kept track of the number of units of a particular type and the ability of my blood supplier to accommodate the order.  Say I was ordering O Negs.  I wanted 4, they said they could only give me 2.  When I said ok they changed my request to 2u instead of the 4 I wanted.  Needless to say they were surprised when they rec'd my QA of their ability to meet my needs over the course of a year.

I agree with John and Malcom.
Future transfusions?  Non-ABO antibodies are mostly 'extravascular' hemolysis and, as I've said before, 'Exanguination is a lot harder to treat than a delayed hemolytic transfusion reaction' so all those IgG antibodies tend to get 'ignored' during a massive transfusion situation.  We actually try to hold the 'totally compatible' RBCs until the bleeding is in control/stopped.  Plus, yes, there's the dilutional and immunomodulation effects of massive blood transfusion.
 
Check the 'Instructions for Use' on your Rh-Ig product.  Rh-Ig prophylaxis is usually recommended for Rh-neg patients who have received less than 20% Rh-Pos of their blood volume.  Furthermore, since giving Rh-Ig to such patients will cause a mild 'delayed hemolytic' reaction (that's how it works), the IFU recommends exchange transfusion if the Rh-Pos transfusion was greater than 20%.  But, as I said, I agree with John S. about all that.
 
PS We have records in our files of patients who developed Anti-D to Apheresis Platelet transfusions ... so, it does happen.  We do consider Rh-Ig per policy, but most of the time the patient is over 50yrs old so this becomes a mute/moot point.

But Malcolm, there is a very subtle but important difference between what is "possible" and what is "realistic".  Personally, I would say that going through an exchange transfusion simply to prevent the formation of anti-D is not reasonable but then I'm married to a nurse who has an anti-D along with an anti-K and an anti-S so my view may be a little jaded. Oh ya, the D was provided by the birth of our son.  Our daughter was effected by it to the point of needing a double exchange transfusion which, I should mention, is not quite as dramatic in an infant as it is in an adult.  The daughter is now 31 and has three children of her own.  I relate this to remind folks that having an anti-D is not the automatic kiss of death.  Ok, enough of my semiannual philosophical drivel. 

What does he package insert on you PeG and you antiglobulin say?  The definitive answer should be found in those areas.
 
Personally, right away seems best to me!

Thanks go out to you and your staff -- thank you for being prepared to handle this situation.  So often the lab folks don't even get recognized for our contributions in these tense situations.  There is nothing quite like that old adrenaline rush to help accomplish what needs to be done!  I am sorry that your community had to experience this sad event, and I pray that healing will happen as quickly as possible.  Pat each other on the back for "taking care of business".

Whatever squeamishness I had was cured during my Peace Corps days in West Africa. We had porcupine, bush rat (agouti), and offal from various critters. I did not try the smoked bats (maybe a good thing, since I've found out since that there was an endemic strain of Ebola there). And I looked at dormice on Wikepedia - they look like a cross between a mouse and a squirrel. Must take a bunch to make a meal, though.

Compliments to you and your staff for handling such a tragedy.  Sympathy to the family & friends of those killed and injured.  I agree....far too many of these types of episodes during the last few years.
 
Donna

Thanks everyone!  We have had an incredible outpouring of support.  They are calling one of the injured victims a hero for rushing the gunman and saving people-he was shot 5 times!  After the first three shots, he fell and told the gunman it was his son's birthday and was shot 2 more times.  Roseburg is also the home of one of the Americans who stopped the terrorist on the train in France.  He works at Costco here.  People are amazing!

Mari, you have been through the fire.  I am certain you and the rest of your staff did us proud.  There are times when you have to shut out everything but what is in front of you and do the job to the best of your abilities.  There is always time later to reflect, and tremble, grieve and cry but the true professional manages to get the job done.  From you post it is obvious your training was well done and your plan well thought out.  It reminds the rest of us why we go through the exercises.
Well done young lady.  You are all a credit to the profession. 

As an addendum, what we do with anti-Sid (love the janitor story by the way) is:
Look for the unique "Sidish" appearance Try to eliminate other ab choices per routine panel techniques Do the urine neutralization on all reactive reagent cells to make sure the rxn go away with the urine but stay with the dilutional control. Find full XM compatible units with straight serum/plasma - usually not too hard. Many panel manufacturers will also indicate cells that are strongly Sd(a+) which can be a clue to what you're dealing with.

My line was always as hard as it is to catheterize a guinea pig, it's even harder to train them to pee into those little cups.........
 
The procedure in the tech manual says to use freshly collected urine and boil it first. Do any of your reference lab types (ahem Malcolm) know what this step is for? It sounds like the start of a secretor study, where the boiling inactivates salivary enzymes that might start to digest your soluble blood group substances. I have happily used pooled urine from 5 or 6 urines with a neutral pH and it seems to work just fine without the boiling, and without dialyzing for that matter. Any danger in this?
 
Thanks - Phil

I came across a patient years ago that had a strong anti-Sda. The first thing I noted was that very distinctive appearance of the agglutination. I decided to try urine inhibition for giggles and it worked great. As mentioned above, a pooled sample from 6 different donors will neutralize the antibody and doing that to my patient's sample totally removed the antibody activity. I did not dialyze or boil the urine - though we did still have bunsen burners in the lab so I could have boiled it...ick.
 
Unlike the rest of the clinical lab, blood bankers can still have fun playing with stuff we read in books - how cool is that!

As an aside, do you know that Sda was originally named Sid? It was named this after Sid Smith, who used to be the janitor at the Medical Research Council's Blood Group Unit, when it was in London, as he had the strongest expression of the antigen at the time it was identified.  In those days, antigens and antibodies were usually named after the first two letters of the surname of such a person, but Sm was already being used for the antigen within the Scianna Blood Group System, that is now known as Sc1, so they named it Sid!!!!!!!!!!
 
 
I love these "Oh, by the way...." stories!  Thanks!
 
Donna

We are a Level II trauma center. We keep 2 group A and 1 group B plasma thawed at all times. We rarely discard these thawed plasma because we rotate them to surgery as needed and thaw more. Surgery has gotten used to being able to get plasma faster so they are happy too. We only keep 6 AB FFP in the freezer at any time.
 
Most traumas that pass thru our doors do not have previous blood types in the computer so there was always a delay to thaw group AB FFP until we had a blood type. I approached the main trauma physician and asked him if he had any issues with giving type A plasma. He was all for it since it would cut the time delay to almost nothing.
 
I talked it over with the Lab medical director who was a bit hesitant but I provided information for him to read. My lab director almost croaked when I told him my plans. I had to reassure him by letting him know we have been issueing non-group specific platelets to patients for years without issues. It also helped that one of our sister hospitals had already gone to this policy
 
Our policy states that we may issue up to 2 group A plasma to a patient of unknown type in an emergency. That should give us time to get a blood type on the patient to begin to start thawing type specific. The computer is set up to allow us to issue group A with a warning that we must override.
 
I feel better because we can provide some thawed FFP in a hurry along with the RBC. We will always be behind in a massive trauma but at least we are not so far in the hole.

No policy yet, but here's a couple good articles, if you don't have these already.
Jnl Trauma Balancing Risk and Benefit article.pdf
Jnl Trauma Emergency Use of group A plasma.pdf

The easy ones first eh KatarinaN!!!!!!!!!!!!!!!
 
It was something I remembered from way back (early to mid-1970's), when I first worked at the International Blood Group Reference Laboratory (I went back there again for a short time as a locum).
 
Guinea pig urine is specifically mentioned on page 402 of Race RR, Sanger R.  Blood Groups in Man.  6th edition.  1975.  Blackwell Scientific Publications.
 
I think it came from a paper they cited:  Morton JA, Terry AM.  The Sda blood group antigen.  Biochemical properties of urinary Sda.  Vox Sang  1970; 19: 151-161, but I would have to check that.  I do remember, however, that we used to keep a supply of frozen guinea pig urine for inhibiting anti-Sda, so, presumably, this worked better than other sources of urine.
 
As an aside, do you know that Sda was originally named Sid? It was named this after Sid Smith, who used to be the janitor at the Medical Research Council's Blood Group Unit, when it was in London, as he had the strongest expression of the antigen at the time it was identified.  In those days, antigens and antibodies were usually named after the first two letters of the surname of such a person, but Sm was already being used for the antigen within the Scianna Blood Group System, that is now known as Sc1, so they named it Sid!!!!!!!!!!

In particular, guinea pig urine.  How you get this is another matter (even if you have a guinea pig) because 1) they keep moving and 2) they won't urinate to order!!!!!!!!!!!

Usually Sda agglutination has a distinctive appearance.  You can also neutralize it with urine (as I recall).  Just pool a bunch of urines and you are bound to have an effective neutralizing soln. (better if you learn to recognize its appearance)

I'm none too sure that I would count LISS as an enhancement medium, but I would definitely count PEG, albumin and enzymes as enhancement media.
We use pre-warmed LISS IAT almost every day in the Reference Laboratory, although we use column agglutination technology as the first "line of attack".
When I started training at the Blood Group Reference Laboratory in circa 1973, pre-warmed saline IAT (with an hour and a half incubation) was the norm. The 90 minutes incubation was largely because that was how long Rob Race and Ruth Sanger took for lunch in the MRC Blood Group Unit, and the BGRL adopted this technique!!!!!!!!!!!!!