John C. Staley

I would like to see studies as to why transfusion services continue to provide ABO non-identical transfusions when they have ABO identical components in stock.  ABO mismatched red cells (so-called universal donor group O red cells), platelets and plasma (so-called universal donor AB plasma) have all been associated in randomized trials (platelets) and observational studies (red cells and plasma) with increased mortality, bleeding and other dire complications.  Why has an entire specialty failed to take notice of data that contradict long standing dogma?  What can be done to improve this performance and reduce suffering, morbidity and mortality amongst our patients?  This is particularly important because ABO non-identical platelets may actually make hemostasis worse, and thus no transfusion is likely better than an ABO non-identical platelet transfusion, as one example.

Not in a blood collection center, so no policy.  But scientifically there is no rationale for donor deferment.  The vaccines are not live/attenuated but rather just protein with no potentially infectious material of concern to recipients.  The virus, in any case, should only infect respiratory mucosa and thus would represent minimal to no risk to recipients even if present in donor blood (similar to coronavirus and influenza).

We have had HFAP until they were purchased by ACHC, and both of those have cited me for the lack of correlations:  one for not performing them at all, although I pointed out that we do that on every specimen without previous records, and just last year because I didn't include crossmatch tests with my Type and Screen correlations.  I contested the citation again, stating that it was the exact same methodology as the antibody screen, but was unsuccessful as their standards say "the same test using different methodologies ".  I gave up and added XM as well.  No concept of what we do and no common sense! 

I only wish I could know another language anywhere near as well as Yanxia knows English!  She has always impressed me with her blood bank knowledge as well.

Blood bank methods aren't expected to correlate perfectly.  We use their differences to avoid rouleaux, clinically insignificant, and weak warm auto reactivity so we can better detect any significant alloantibodies. No method will detect 100% of significant antibodies. I am going to tweak the above to say we can "better detect' antibodies so it works better with the next sentence and doesn't imply that we can detect "any" significant antibodies. 

I like it Mabel! We all need to start using that for our CAP inspections to see if we can shove them in the right direction.

When TJC inspected us last year, we weren't cited but she recommended that we include in our QC policy for the lab why we don't do BB correlations.  I finally got around to writing this up.  Did I miss anything?  Is anything in error?
No published evidence or immunohematology expert supports periodic method correlations. Blood bank methods aren't expected to correlate perfectly.  We use their differences to avoid rouleaux, clinically insignificant, and weak warm auto reactivity so we can detect any significant alloantibodies. No method will detect 100% of significant antibodies. If they don't correlate on a given sample, there is nothing to be done to "fix" the methods. Deviation from manufacturer's instructions violates FDA and other regulations.  It would be extremely complex and probably futile to try to validate all changes that would make all specimens correlate. To select a specimen for correlation testing that is expected to correlate between methods while avoiding those that won't correlate is unscientific and a waste of resources.

If we have to hunt for a sample to use for this that will give consistently comparable results, we aren't testing the method, we are testing our ability to find a suitable sample.  I heard that CAP will sell you one that will consistently give the same results.  If we aren't going to change anything (can't recalibrate gel!) based on the answers we get (like chemistry would), then why are we doing this?  I talked TJC out of it last inspection (I probably got a little heated over the stupidity of it because I had to come in the day after a concussion to meet with them, but maybe they took pity on me and didn't cite me because of my unfiltered brain).  No one has been able to explain to me any meaningful takeaway from doing this comparison.  If I am ever forced to do it, we will just keep copies of sample results that we run by two methods to solve a problem and make a note that they are acceptable because we expect these differences between methods.  If anyone can give me a valid use for this, I would be very appreciative.

Our Red Cross just informed us that it will discontinue providing CPDA-1 rbc.  We primarily used it to provide volume reduced red cells to pediatric patients under 3 years of age.  We will volume reduce AS-1 or AS-3 by centrifugation or washing (Terumo 2991) instead.  Probably unnecessary for most patients, but this is a long standing practice here, and it doesn't seem worthwhile trying to adjust pediatric practice in this regard.  Most patients do not need the additional volume provided by the anticoagulant-preservative in AS-1, etc., and avoiding unnecessary volume is a reasonable goal in many patients. 
There is no inherent virtue to CPDA-1 vs. AS-1 and similar solutions, and rbc preservation is slightly better in AS-1/AS-3 by in vitro metrics.  There is absolutely no factual basis for using CPD-A1 in preference to AS-1, etc. in pediatrics.  Purely expert opinion and probably unduly conservative.
 
I've attached a nice presentation by Dr. Saifee at the University of Washington, who createdAdditive solution AS-1 in Children Univ. Washington presentation Dec 2021.pptx it to educate her colleagues about using AS-1 instead of CPDA-1.
Additive solution AS-1 in Children Univ. Washington presentation Dec 2021.pptx
Pediatric RBC White Paper - November 2021.pdf

Sorry,I can't find the English version.The  underlined sentence means the cord blood cells needed to be washed at least once before testing.

I am so lazy that I just checked our IgG card today . I noticed it said that cord blood need to be washed before testing. I am at home now, I will attach the package insert tomorrow.

I'm afraid I still can't agree with this methodology, for a couple of reasons.
Firstly, antibody/antigen reactions are, largely, governed by the Law of Mass Action.  As a result, and given a steady state of conditions (e.g. temperature), however long the incubation time may be, once a state of equilibrium is reached, there will be no net gain of antibody coating antigens, however long the incubation time may be extended.
Certainly, LISS will increase the rate of association of antibody and antigen enormously, but this will apply equally to the auto-antibody as any allo-antibody that may be present, however, of course, some antibodies will only react visibly with red cells that have homozygous expression of a particular antigen, and, if such an antibody is present, it will be very difficult to detect in the presence of an auto-antibody, but can still cause a haemolytic transfusion reaction, albeit, usually a delayed reaction, but it can still cause damage to the renal system in particular.

For these reason, I would always perform an adsorption, to get rid of the auto-antibody, even if I had no intention of performing specificity tests on the auto-antibody (although, it goes without saying, I would go all out to try to ascertain the specificity of any allo-antibody detected).

I am trying to write a book at the moment, called "Human Red Cell Serology and Blood Groups for Beginners", and Chapter 2 deals with Serological Techniques.  I attach the draft copy, which also gives relevant references, the odd diagram and abbreviations I use throughout the various chapters.
Chapter 2 Serological Techniques in Routine Blood Transfusion and Red Cell Immunohaematology Laboratories.docx Chapter 2 Serological Techniques in Routine Blood Transfusion and Red Cell Immunohaematology Laboratories Figures.docx Abbreviations.docx

I've had further thoughts upon this case (having told you not to worry about it - I live a sad life - NOT!).
It struck me that the patient has an Rh type of D+ C+ c+ E+ and e+, suggesting that the probability is that the patient has a genotype of DCe/DcE (R1R2), but this may not be the case.  She could have one of the rarer Rh genotypes, such as DCE/Dce (RzRo), DCE/dce (Rzr), Dce/dCE (Rory), etc, and this may be potentially important.
Some years ago, Joyce Poole explained to me that most grouping reagents labelled as anti-C are, in fact, a mixture of anti-c and anti-Ce, and this, she told me, included most monoclonal anti-C reagents (which surprised me, to be honest).  This is because the vast majority of the red cells transfused that stimulate an anti-C would have the haplotype of either DCe or dCe, or both, and will, therefore, also stimulate an anti-Ce.  As a result, these "hybrid" anti-C/anti-Ce reagents will react more strongly with red cells expressing the Ce compound Rh antigen (Rh7) and the C antigen (Rh2), than with red cells that only express the C (Rh2) antigen.
This would not, incidentally, explain the stronger than normal reaction with the e antigen.

However, if the patient does express one of the rarer Rh types mentioned above, say she is RzRo, she can actually produce an allo-anti-Ce, and most antibody panels only contain C+ red cells that are only Ce+ as well.  In other words, her antibody in the plasma MAY be identified as an anti-C, whereas it is actually a monospecific anti-Ce, which would neatly explain why she has an apparent anti-C.

Of course, she may also have an auto-anti-C, or a mimicking auto-anti-C (and, possibly, an allo-anti-Bg of some sort).  Sadly, for a nerd like me, I doubt if we will ever know!
I think it was John C Staley who once accused me of looking for zebras, when I hear horses hooves (I may be wrong, but I think it was John).  Anyway, this proves that he was absolutely correct about me!!!!!!!!!!!!!!!!!!!!!!!!

Sorry.  I never did get back to this after my holiday.

I still haven't come across a brilliant book on the subject, but four books I do like are shown below, and (sorry for being egocentric) so is one of my own lectures that touches upon the subject.




Serological Techniques for Antibody and Antigen Identification.pptx

True, but the point is, to make this joke of a requirement worthwhile, rather than just a box ticking exercise, there should be specified specificities, but they won't do that because they know (or, rather, should know) that they could never get sufficient of "weak" antibodies of certain specificities, and that diluted "strong" antibodies will have a completely different association constant, and so using these diluted "strong" antibodies will serve to control/compare absolutely nothing.

Exactly! We have to do it, but make the plan 'reasonable' for your facility.

When I was working on-call in a hospital laboratory, I was a lone worker.  I gave out blood, blood components and blood products without anyone checking me, apart, of course, from the patient's own immune system!

As far as I know, and I think I would, none of them had either an immediate or fatal haemolytic transfusion reaction.

If you give the same product to all patients regardless of age, blood type, gender etc. then why an extra check?  Assess the risk for this product being infused improperly and compare that risk to other things that require 2-person check to see if it is anywhere near equivalent.  Probably there was some historical computer system that required it and now it is "how we've always done it".

Ours print on a 4" x 4" label from a Zebra type printer. We stick them on a slightly larger tag made from card stock with an eyelet at the top for a rubber band. The back of the card stock tag is printed with a list of transfusion reaction symptoms and a brief description of response expected. Below that are blood handling instructions/education. All nursing documentation is in Epic.

QUITE RIGHT TOO!

I'm annoyed! Yes, there are differences in results between automation, GEL and tube testing. Automation is the most sensitive and tube testing is the least sensitive (but the BB gold standard method), with GEL in-between. I wrote that bit of information in my procedure so an inspector would know I am aware of the possible differences.   We are doing this exercise to make sure the methods compare, if the specimen is positive in automation, it should also be positive in GEL and tube testing and should appear to be the same antibody on the antigrams. If I am doing an antibody screen and an AB ID, I am using the same METHOD whether I am testing using 3 screening cells or a panel of 10 or more cells. 
Yes, we have the rare antibody screen that gives wonky results in automation and and is stronger in GEL. That tells me we need to do the ID in GEL so we can actually get an answer we trust. Different antibodies work differently in different methods but the screen and AB ID should be the same within the same method. Our screening cell method in tube is the exact same method as our panel tube testing. If I am doing the comparability testing, I am using a strong antibody that has a 3-4+ result so I can be assured I will get similar results across all 3 methods. I'm not going to use a weak or wonky antibody that would give shady results an inspector could question when they view my forms at an inspection.
This is Method Comparability, not Test Result Comparability. Does CAP have to have a quota of standard changes they have to meet? I'm on a soap box and I am sorry to rant but this seems unnecessary and extra work for the same AB screen results across the different methods. 

So, this PROVES that CAP do not know the A from their elbow.
ALL Blood Transfusion Reference Laboratory Staff, not to mention MOST Blood Transfusion Hospital Laboratory Staff KNOW that not all antibodies can, by any means, be detected by ALL serological techniques (saline, albumin, enzyme, LISS, IAT, inhibition tests, recombinant blood group proteins, etc), let alone by ALL technologies (glass, tube, plastic tube, liquid phase microtitre plates, solid phase microtitre plates, column technologies, etc), BUT THOSE WHO RUN CAP KNOW BETTER THAN EVERYONE.

They should be thoroughly ashamed of themselves, and go back to kindergarten.

We are in our inspection window now, so I'll let you know how we come out on that one. 

Personally, if push comes to shove, (which it often does when dealing with closet dwelling bureaucrats) my reference range would be POSITIVE (POS, +) - NEGATIVE (NEG, -).  I don't think I would want to confuse them with indeterminant. 
   

Personally, if push comes to shove, (which it often does when dealing with closet dwelling bureaucrats) my reference range would be POSITIVE (POS, +) - NEGATIVE (NEG, -).  I don't think I would want to confuse them with indeterminant.