John C. Staley

Linda, is this hypothetical or real? If it's real I would be interested in how "you" tell her NO and how she takes it. I have to agree with the logic of your concern. If we (our local blood supplier) is not making FFP from women why on earth would you want some one to take this kind of a chance! Hopefully you can get the patient's physician to explain it but that may not be the case.

Anyone try an infrared thermometer for this? Maybe you can just zap the bag from the outside and get the reading. I don't know becasue I don't have one but sounds like something some one with one could try. I know a lot of folks use them when checking the temp of RBCs brought in or returned from the floors.

AABB Std 5.18.3 deals with the re-issue of blood products. Section 2) of this std indicates that the blood product must be "maintained at the appropriate temperature." to be acceptable for re-issue. The current thinking is that this temperature for RBCs is 1-10oC because the prevailing thought is that this is considered "transport" and not storage. If you issue the blood in a cooler the FDA has determined that to be storage and the acceptable temp then becomes 1-6oC. We check the temp of all returned units. If they exceed 10oC and were not issued in a cooler we have the option of dicarding them immediately or re-issuing as long as they are transfused completely within 4 hours of the original issue. The 30 minute rule apparently was developed during the era of whole blood and glass bottles. Our experience is that it takes about 15 minutes for a unit of PRBCs to exceed 10oC at room temp.

Linda, Some places have gone to providing only type O to OR and ER until they get a second sample. I guess that all depends on the depth of you O inventory and how often it would happen. I've heard of more than one ER that got smart and would draw 2 samples holding one for "later" if needed. It's amazing how creative we humans can be!!! Especially if we can come up with a better way! (Better usually means easier for me.)

Our rules/guidelines are similar to Linda's except our corporate transfusion medical director set the gestational age at 13 weeks instead of the 20 weeks Linda indicated for the need for fetal bleed screens.

It's not just you, this is a standard of practice at most places including my own that I personally have issues with but have been unable to get much attention for. The numbers are small and no one seems concerned. It's just an argument in logic I like to raise every chance I get. It makes people think and that is a good thing.

Larry, I'm curious, what sample do you submit to the blood supplier for testing? One from the implicated unit? We contact our supplier and they will contact the donor for testing, that is unless the donor is a male with no transfusion history. Then they refuse do do any testing.

My understanding is that 24 hour plasma and 5 day plasma are essentialy equal in factors but have reduced labile factors when compared with FFP. (How much reduced varies with the studies you read but not by much.) Our clinical pathology group has decided that the difference is not enough to worry about so we use them interchangably.

So.... if the patient is an A and you continue to give O then you keep adding to the anti-A and anti-A,B load which continues to attack the patients cells. You are just continuing to feed a vicious cycle. I'm afraid that this is one discussion where the logic of giving a baby who has mom's anti-A in them, type O cells containing more anti-A has complete escaped me. I simply can not follow the logic of pouring more gasoline on the fire you are trying to put out.

Relying on your own experience is a good place to start but the extensive study literature seems to indicate otherwise. A second sample will catch both problems while re-typing the same sample, at best, does half the job and the more uncommon half at that. Granted, it is far easier and quicker to re-type the original sample but the studies indicate that this is not where the majority of the problems occur. Sorry but this is one of the few subjects where I am very unlikely to change my opinion. But you are welcome to try.

I must be out of the loop. What has changed?

A second type on the same sample is of no value what so ever. If you are going to required a second type any thing other than a new sample is nothing more than smoke and mirrors!!

Mabel, you'll never know the answer to that if you don't subscribe to the JAT (automated testing) CAP proficiency series. The J series just compares the manual use of the technology and does not take into account the automated users.

Morning Linda, Yes we are doing donor confirmations / unit retypes on the Echo. They are much more user friendly on the Echo than they are on the ABS2000. January was our 1st full month of testing and the numbers are pretty good for us. 472 Group and Screen 215 Donor confirmations 86 groups 29 screens 9 antibody ID's 89% of our antibody screens were run on the Echo. So far so good!!

It works kinda like a batch analyzer only not quite. I'll try to explain. If I put 4 group and screens on the Echo I can keep adding group and screens and it will start them in sequence as they are loaded but if I add an antibody ID it will, essentially, have to complete all of the group and screens before starting the ID. This is even more pronounced with the wD testing. If I have a group and screen and have it reflex the wD testing for an Rh neg. and I add another group and screen once the wD testing has started it won't start the G&S until the wD is completed which can take 30 min. from start to finish. The through put is very good as long as you keep loading the same test. The problem comes if you try to mix and match. We had a case a couple of days ago where one tech put an ID on and a second tech loaded a stat G&S. The first tech did not say anything and the stat test was on the analyzer for about 15 minutes before the testing even started. That's still a 37 minute turn around time for stat which isn't bad it's just frustrating. We are considering a 2nd Echo, the first for G&S and the second for everything else. We are not computer interfaced. Our computer is a very old version of Lifeline/Western Star and incapable of such sophistication as an instrument interface. We are in the process of getting a new computer system and it will interface with the Echo. As that progresses I'll keep everyone updated.

If we have a record of a negative antibody screen during the current pregnancy we do NOT repeat the antibody screen for a post partum RhIG. This way we don't have to waste time, effort and $$$$ identifying passive anti-D due to the antenatal RhIG injection.

We finished our validation and started testing and reporting patients on December 14th. So far no significant issues. The techs are using it extensively and so far are pleased with the operation. We have found a few issues that were more a reflection of our expectations than anything else. It is not a true random access analyzer like the chemistry analyzers are but it is certainly a big step up from the ABS2000. Automation is an evolutionary process and this is just the second step. That's what I keep telling my self and it seems to make sense.

We did replace our ABS2000 with an Echo. Started testing and reporting patient results on 12/14/07. So far so good. It is a new analyzer (our serial number is 124) so we expected a few problems. So far nothing over whelming. A few bugs and Immurcor is addressing those with some already fixed. Looks like we may be asking for a second Echo in the not too distant future. A Galileo was too big for us but we were not sure if one Echo would be enough. Right now we are keeping our old ABS2000 as a back up but I'm not sure how long it will last. We've been testing on it since 1999.

I'm one of those old blood bankers Larry is referring to. As far as I've seen it's just the most current "management fad of the week"(MFOW) and I've seen a lot of them come and go over the years. All of them have had some good aspects and some not so good. The problems I have seen from these "fads" is that they were developed for industry not health care and I don't care what you say we are not the same as a potato chip factory!! We are constantly evaluating our processes and don't need any funny colored belts to do it. My staff are always asking why we are doing something a certain way when they see a "new and better" way to do it. Would formal training in one more MFOW be of any use, maybe, but just as likely not. If you find a system the works more power to you. If you find a way to modify it to be more relevant to the heathcare setting you've just found you early retirement.

Franklyn, what alarm system are you referring to? We are considering getting such a system and a validation aid could swing the vote.

"One observer at our laboratory has voiced an opinion......" I'm curious, who was this "observer" and what did they base their opinion on? For everything but hives, we do a clerical check, a hemolysis check and on the post transfusion sample a DAT and ABO/Rh. If any of these are of concern the work-up gets real interesting. Otherwise we're done. Oh yeah, for certain things we will also do bacterial studies but that is another story.

We do not cofirm the antigen testing coming from our blood supplier. I have never seen a JCAHO requirement for this or any other agency for that matter.

That is a possible concern, especially with anti-Jka and anti-Jkb. They have a nasty habit of dropping below detectable levels and then popping up as a delayed transfusion rxn. This is one of those issues that asks the question: where is your paranoia level? Obviously you would be more comfortable recrossmatching. But, would this not be the same for a patient that was crossmatched for 4 units, received 1 on day 1, a 2nd on day 2 and then they wanted to transfuse a 3rd on day 3. Would you then re-crossmatch the 3rd unit? It certainly falls within guidelines to simply issue that 3rd unit on day 3. The only difference between this scenerio and the original one posed by nikka8506 is the 1 day lag between the original crossmatch and the 1st transfusion. I think the general concern with the 3 month period is not old antibodies that have dropped below detectable levels as much as it is with newly developing antibodies that have not yet reached detectable levels. As I indicated above, we would have simply requested a new sample and retested the patient in the original scenerio but not for fear of an undetectable antibody but because it is just easier than identifying all the times we would not need to. One other thing about this scenerio, we have always counted the day the sample was collected as day "0" not day "1". It's like birthdays. You were not born 1 year old. That 1st birthday did not come until you completed that 1st year.

The general concensus is that anytime within 3 months after a transfusion or pregnancy an antibody can be produced. If, after 3 months, there is no antibody the patient is highly unlikely to produce an antibody do to that transfusion or pregnancy. Every transfusion or pregnancy is a new opportunity and resets the 3 month clock.

Our SOP is to release the remaining 2 units and re-crossmatch on a new sample. Logically it doesn't make a lot of sense if your patient has not been transfused or pregnant during the previous 3 months but sometimes it's easier to stick to the easy rule than identify all the exceptions. :abduction