John C. Staley

Malcolm, my questions were directed specifically to applejw and the several examples mentioned.  I was assuming they were fairly recent, at least in the last couple of decades and that info might be available.  In 1967 I was in Jr. High and did not even know there was such a thing as blood banks!

If I'm not mistaken, both of those examples were whole blood units, not packed RBCs or RBCs resuspended in ADSOL. That would impact the amount of antibody transfused.

In the UK, such a unit would be offered to the National Frozen Blood Bank, and would only be frozen AFTER a thorough aseptic wash, followed by addition of a chemical to prevent the formation of sharp ice crystals, and then  more washing upon thawing.  There would be no allo-anti-Kpb left!

I've been thinking about this question and I don't remember if our SOP specified what type of cell to use (I've slept a couple of times since last performing a titer).  What I do remember was that we wanted to use the same type with every repeat during the pregnancy.  In other words if the initial titer was done using an R1R1 cell for anti-D then every subsequent titer was performed with an R1R1 cell.  At the time, the change in titer was considered the most important finding.  Also, again I'm trying to awaken long dormant memories, we used a tube/saline or tube/albumin technique ( can't remember which) because that was how the original studies were done for anti-D and how the values utilized by the OB docs were derived.  I know this is ancient history for many of you but thought I would throw it out there.  
I seem to remember that titers were going out of vogue  about the time I retired and there were much more accurate methods of determining the effect on the fetus from maternal antibodies coming into use.

 

Thanks for the link!  I found the full version and it is now bookmarked.
I wish the US would come out and pick a side.  They should know us lab folk enjoy the comfort of the black and white.  Grey is for those making the rules.  Haha!

Well stated @Malcolm Needs!
Semantics aside, I do see the reasoning behind either antigen configuration. Definitely different purposes though.
I did reach out to CAP to ask which they are using for their Anti-D titer PT sample.  Seems that if we are tasked with being in range with peers or their "answer key" I'd like to know what they are using as routine.  They have no documentation of what guidelines they routinely use for titer cell selection.  Hmm.. 

Well, the first thing to say is that red cells CANNOT be either homozygous or heterozygous (or, come to that, hemizygous).  These terms apply ONLY to genes, and red cells do not contain a nucleus.  The antigens can only be described as, at best, "homozygous", "heterozygous" or "hemizygous" expression, or, alternatively, "double" or "single dose" expression.

Then, it HAS to be accepted that, unless the maternal antibody is an autoantibody, it must be an alloantibody (or, possibly, an isoantibody), which means that to mimic the state of the foetal red cells, the red cells used to titrate the antibody MUST have a "single dose" expression.  However, that in itself presupposes that the foetal red cell antigens are all expressed at the same time, which we know is untrue (just look at the A, B and H antigens as an obvious example, but also the Kell antigens that are expressed much earlier than are the Rh antigens) or are ONLY expressed on foetal red cells, as opposed to other tissues (such as on the placental cells, which have, in some cases, been proved to adsorb the maternal antibodies).

Then, there is the fact that not all antibodies can be detected by all techniques.  This is why Reference Laboratories SHOULD have more than one technology available (and their workers should be provably competent in these techniques.  However, even then, not all techniques can predict the severity or otherwise of HDFN.  For example, antibodies within the Indian Blood Group System always show that they can cause severe HDFN by certain techniques, such as MMA, but they don't!  There is also the fact that the immunoglobulins may be IgM, IgA, IgG1, IgG2, IgG3 and IgG4 (to mention just a few), and I have yet to come across, or read about, an IgG4 immunoglobulin causing HDFN.

So, my answer is that there is a HUGE amount of knowledge known about the various antibody specificities, their titres, the expression of their cognate antigen, etc, etc, that there CANNOT be a single answer to your excellent question, but that the best thing that can be done is to read around the subject - and read around the subject from every source available - not just from a single country.

OKAY THEN, RIP ME APART!!!!!!!!!!!

Just be aware that dry ice turns into a gas.  I presume your freezer is not fully airtight, but it could open rather violently depending on how tight it is sealed, and how long since the last time it was opened.

Best story/advice I've heard in a long time!!!  Thanks for sharing it.

All, I am about to blow your mind....
Our plasma freezer is down and so is our backup. The freezer will not get colder than -18 C. I was preparing to move all the products into boxes with dry ice until I had a conversation with my 87 year old dad, a retired blood banker from University of Chicago. He said to me, do not take the plasma out of the freezer and put it in boxes, PUT THE DRY ICE IN THE FREEZER, IT IS THE BEST STORAGE BOX YOU HAVE!!!!
MIND=BLOWN!!!!
I did that. Our freezer is currently reading -25.1C and getting colder. Furthermore, the probes in the freezer continually monitor the temp in the freezer so you don't have to record temps every 4 hours, the chart is doing that for you!!!
Isn't that cool? That perfectly illustrates the difference between wisdom and knowledge there. I wish we could hire my dad.
I just had to share this here.
PS. Freezer is now at -26.4C.
 

You did everything that was required in this situation. The patient was a trauma and needed emergency transfusion. The risk of death outweighed the risk of a hemolytic transfusion reaction in that scenario, according to the treating physician. I once had a trauma surgeon tell me "I can treat a transfusion reaction but I can't treat death!" That put things in perspective for me. That is why thy sign the consent.
Next step would be to report this to your risk management department so that follow-up can be made, including monitoring the patient for the s/s of DTR. 

Malcolm, I meant that statement not as a criticism of them but just a recognition of reality.  Frankly I was excited to get the forms back most of the time and fully understood the pressure they were under.  When I was in school I worked in the emergency room on night shift so I was very familiar with trauma situations and fully understood the, "do it now and worry about the paperwork later" mentality. 
Cheers  

What I noticed over the years was that many times when faced with signing for uncrossmatched blood the physician would take a second to reevaluate the situation.  Often they would then respond with something like,  I want it crossmatched so hurry.   Not always but it was not uncommon or rare.  When they did sign the form it was most often when the crisis had resolved and the dust settled.
 

You may not "mean to offend" but that does not make it any less offensive.  If you have nothing helpful to contribute it's best not to. 
I have worked in level 2 trauma centers with 24 / 7 coverage in the blood bank.  I have also worked in a rural clinic in a Wyoming county the size of most states east of the Mississippi and there was not hospital in the county.  The closest hospital was 2 hours by ground and if we needed a trauma center it was at least 3 hours to get a helicopter or airplane in and out.  You do the best you can with what you have.  The people of the county realized that one of the prices they had to pay for living in one of the most beautiful areas in the world was limited access to health care.  They understood, accepted it and were actually grateful for the level we could provide!  They neither wanted nor needed ..........   I best stop now. 

Another idea.  Not mine, but I wish it was!
 

Small rural critical access hospitals operate under very tough conditions. If they close their doors the next closest facility, which may also be a critical access hospital, might be an hour or more away. It's a world I am thankful I am not working in, though my facility is one that receives transfers from critical access hospitals after they stabilize and ship.

They probably barely have enough staff to cover what they cover now if they are a small enough facility to not have a night shift. 

we treat PEG as another enhancement, so no difference in charges

I always considered antibody identification both art and science with a little magic thrown in for good measure.  

It's never safe to assume that everyone, or for that matter, anyone knows what you are talking about when providing one short sentence.  Especially us old, retired guys.  Both Malcolm and I thought you were looking for some philosophical discussion.  Hope you find the key you are looking for.

It's never safe to assume that everyone, or for that matter, anyone knows what you are talking about when providing one short sentence.  Especially us old, retired guys.  Both Malcolm and I thought you were looking for some philosophical discussion.  Hope you find the key you are looking for.

It's never safe to assume that everyone, or for that matter, anyone knows what you are talking about when providing one short sentence.  Especially us old, retired guys.  Both Malcolm and I thought you were looking for some philosophical discussion.  Hope you find the key you are looking for.

I do think that one sentence makes for a good philosophical discussion

It's never safe to assume that everyone, or for that matter, anyone knows what you are talking about when providing one short sentence.  Especially us old, retired guys.  Both Malcolm and I thought you were looking for some philosophical discussion.  Hope you find the key you are looking for.

I have to agree with Malcolm.  In the 35+ years I spent in blood banks and transfusions services I saw and trained many Clinical Laboratory Scientists.  I have to say that there were a noticeable few who just did not have the talent for it.  No matter how knowledgeable they were in the science they just could not see it.  I might even argue with Malcolm's 75% science.  I'm leaning more to a 60-40 ratio.