scodina

We currently wash red cells for IUT procedures. We have been having difficulty obtaining washed RBCs lately. We do not have a cell washer and our blood supplier has stopped washing cells. I saw a thread on the CBBS website indicating that washing red cells for intrauterine transfusion is actually contraindicated, because it lowers the hematocrit of the unit. Higher hematocrit levels are better for the baby. AABB does not state that washed red cells are required for IUT unless you are using mom's blood (in the event that she has an antibody to a high frequency antigen). I have spoken with our perinatologists. They are willing to switch to non-washed red cells if I can show them documentation. Is anyone aware of a study or book that support this? Thank you!

In addition to the above, we add instructions: Only blood products may be stored in the cooler. Do not put platelet products in the cooler. Return the cooler to blood bank immediately when blood is transfused or no longer needed. etc.... I think the only things you are required to put on the cooler are a unique identifier and a biohazard sticker.

I would recommend QCing some reagents if you also perform testing on the bench. You are not just QCing the reagents, but also the cell washer, centrifuge, heat block, etc. What methodology are you using on the bench? Much of what has to be QC'd will be depend on whether you are using the same methodology or a different methodology.

Does anyone know if there is data to support rinsing an empty bag with saline and culturing the saline following a suspected septic transfusion reaction? We are in the process of overhauling our transfusion reaction SOP and this question came up.

My blood bank stores and issues all RhIg doses for all OB patients. Our current outpatient (28-week dose) procedure is to draw a T&S on mom and armband her with a blood bank armband. If she is Rh-negative, we will recall her. If she returns within 72 hours with her armband on, we will give her RhIg. If she returns after the 72-hour window or cuts off her armband, we will re-armband her, redraw the T&S, and make her wait 3 hours while we test it prior to giving RhIg. This is a ridiculous procedure that makes both the patient and the physician mad. I am trying to get buy-in from the hospital to change the current process. However, I can't find any data to support the idea that the prophylactic, 28-week dose of RhIg does not have to be given within 72 hours of the T&S test. Our BB Medical Director firmly believes that the woman could develop an anti-D after 72 hours and that we would not be able to discern Anti-D from passive Anti-D due to RhIg at the time of delivery (not that it would matter for the current pregnancy). My biggest argument right now is that patients will forgo any RhIg and develop real anti-D if we make the process too difficult. This is the first hospital I have worked at that actually administered the antenatal dose of RhIg, so I am unsure if this is truly the practice in other locations. I have also tried to pull up the OB treatment recommendations for RhIg, but they just say "28 weeks." They don't list a specific timeframe from the ABO or antibody screen tests. Help! I need suggestions

We are a trauma center and run many K-B's on pregnant women who have had trauma. Our routine protocol is to monitor mom for 4 hours then discharge as long as there is no other reason to keep her in the hospital. Per our OB department, there is a very strong correlation between fetal demise and a positive K-B. Our physicians do not use this as their only monitoring method. However, they do increase the amount of time and level of monitoring when the K-B is positive. I admit K-Bs are not the most accurate test, but NSTs and ultrasounds can also yield false negatives with small bleeds.

We do not genotype ourselves, but we do send patients out for genotyping frequently through our reference lab. Do you have specific questions?

Question for those of you performing a fetal screen on pregnant moms....are you sure your results are accurate? For the fetal screen to work, the mom must be Rh-negative and the baby Rh-positive. How do you know the baby's type in utero?

We are in the process of implementing this testing. We are only testing group O platelets. We plan to use a dilution of 1:100 againt a and b cells in an IgG gel card. If the reaction is positive, the platelets can only be used for type O recipients. Those platelets that are negative can be issued to any type recipient. We chose the 1:100 dilution based on a cont ed program I attended that stated this is the European standard. Stephanie

Question.... I recently had a physician ask me if there is a way to tell whether a fetal bleed is acute or chronic. Does anyone have an idea of how to differentiate between the two? We initially looked at the babie's retic count, but that was not helpful. Can you think of a better way? Thanks! Stephanie

I have responded to this post off-line, but I do want to refer the rest of the group to the following journal article: Yazer MH, Cortese-Hassett A, and Triulzi DJ. Coagulation factor levels in plasma frozen within 24 hours of phlebotomy over 5 days of storage at 1-6C. Transfusion 2008;48:2525-2530. Stephanie

I will be happy to share our checklist with anyone who would like a copy. We added the requirement that we check all shifts (day, evening, and night) at least once per month and we now require the nurse manager to forward a copy of the transfusionist's training records to us following audit. This helps us ensure that nursing training is documented and ongoing to meet regulatory requirements. AABB has some checklists listed on their best practice website also. Does anyone have a tool to audit the blood bank end of things that you would be willing to share?

There is a 3rd edition of the Judd book available as of 2008. If you are trying to locate it, the actual name is Judd's Methods in Immunohematology. The authors are W. John Judd, Susan Johnson, and Jill Storry. I bought mine on the AABB website.

The Transfusion Service Manual of Standard Operating Procedures, Training Guides, and Competence Assessment Tools by Lucia Berte is available through AABB. It offers procedures, flow charts, and a training competency for txn rxns as well as a lot of other basic BB tasks. I would recommend this book to anyone looking for basic building blocks on which to develop BB procedures, etc.

We are in the process of reviewing the informed consent process at our hospital. During my review, I noted that the AABB Primer of Blood Administration says that hospitals are required to obtain informed consent prior to administering blood components and plasma products to include Factor concentrates (Factor VIII, Factor IX, etc). Recombinent Factor VII is specifically excluded and it is listed as a "pharmaceutical related to blood products." I have always thought of Factors as a pharmaceutical vs. a blood product, because I have never worked in a blood bank that actually dispenses these. However, I have learned that we currently do not obtain informed consent from the recipient prior to administering these products. I am wondering how other facilities are handling this. I think there is probably room for interpretation in the standard, but the Primer is very clear.

We have been very lucky in that we have a great relationship with the OR. I walked into a job in which I am responsible for both BB and some tissue/skin products. We have a very functional tissue committee that meets monthly and consists of personnel from the lab, OR, Infection Control, and purchasing/materials management departments. It is lead by a pathologist (AKA Director of Tissue and Biological Implant). We also have a tissue coordinator who is in charge of all biological products and implants in the OR. The committee spent quite a bit of time creating a set of policies and procedures for dealing with all things implant. Initially, I think it was a challenge was to limit who can order tissue into the hospitals, surgery center, clinics, etc. Materials management has been very good about helping with that. We have a list of approved vendors for certain products to ensure that we have all of their licensing information on file. There are a few people who have the privilege of ordering. We also have a process to follow if a product happens to show up. If a physician wants to add a new product, he/she must first request approval from the Tissue Committee and then VAT committee. Our tissue coordinator tracks Tisseel, room temp products, and those products with special requirements (ie....can't open the shipping box until you are ready to implant, etc.). Blood bank tracks all frozen bones and skin.

We do not give washed platelets after a PTP reaction. We do give crossmatched or HLA-matched platelets. We only have one current patient who has had a PTP reaction, and she has not had a problem tolerating the crossmatched platelets. Her initial reaction was quite severe. She was a multiple-trauma patient who required several life-saving surgeries during her first few days in the hospital. Her platelet count first dropped on Christmas eve, so there was a slight delay before we could get her crossmatched/HLA-matched platelets.

Are you having trouble getting B red cells also? Can you tell me a little more about your suggestion to give O red cells instead of B? Just curious. Thanks!

We actually have the nurse release the blood product via LIS when he/she is ready to transfuse. The "Release" prints in BB. We issue the blood and sent it to the floor via pneumatic tube. The person receiving the unit will sign the release form and return the form to the BB via pneumatic tube. We save the forms for 3 months then discard them, because we have a computer timestamp of the release request.

We have a letter printed on hospital letterhead that basically tells the patient he or she received a blood transfusion and, though uncommon, a patient can have a reaction after they have been sent home. It tells them to look for symptoms like red urine, yellow color to skin or eyes, chills, fever, vomitting, or difficulty breathing. If they experience any of these symptoms the instructions tell them to call their physician or the hospital clinic and lists the phone numbers. I believe it also tells them to go to the ER if any of the symptoms are severe.

We purchase our pre-pooled cryo from the American Red Cross. They make pools of 5 cryo, so we generally give out 2 pools as one dose. It is wonderful....especially when you are in a time crunch.

We try to issue red cells and plasma in equal numbers during a massive transfusion incident. However, we only keep 2 AB thawed plasma on the shelf at all times, so we often do not meet this for the first cooler. That said, we are in the process of creating an objective blood utilization review for patients on the massive transfusion protocol. One thing I have unofficially noted during my reviews is that this plasma often gets transfused even though the INR is 1.2 or less. Therefore, we will likely change this protocol in the future. As for platelets and cryo, I do not believe the data is there to support giving prophylactic platelet or cryo transfusions even in a massive transfusion situation. As part of our new utilization program, we are proposing that the blood bank attach tubes to every 10th unit or RBCs that is issued. We pre-place a line of fluorescent green tape on the top of the tubes and put them in a colored biohazard bag that is different than all other biohazard bags used in the hospital (both of these are for lab recognition). Clinical staff is expected to draw a platelet count and fibrinogen and send it to the lab super-STAT for testing. The goal of doing this is to remind the physicians to test these parameters. I think that when they are attending to a massively bleeding patient, they are doing all they can to keep the patient alive. It is amazing how quickly time passes when the adreniline is pumping! Even though they know they should be testing these parameters every so often, the every so often goes by quickly and probably does not get done as often as it should. The lab will call results to the clinical location and, if results are abnormal, that will be the flag that tells the physicians to order platelets or cryo. By using this method, the BB wins with utilization (we are not indiscriminately sending products out the door) and the physicians maintain control of the orders.

Thank you to everyone who replied to this message. I have been out of the office for a few weeks and have been very bad about checking the thread while away. I found everyone's response very helpful and I would love the contact information from Detroit if you would be willing to provide that. My e-mail address is stephanie.L.codina@healthpartners.com. I am glad to see that may of you indicate your MTP dictates when coags, platelet counts, etc need to be drawn. I think that is what we have decided to do.....essentially let the lab results indicate when cryo and platelets should be given. We give rbc's and plasma out in equal numbers based on the military's research suggesting that this ratio demonstrates improved patient survival. However, we often run into the scenario where the red cells are given and the plasma is returned. I was able to discuss this with Anesthesia lately and received a valid reply. Essentially, they stated that they recognize that red cells and plasma should be given in a 1:1 ratio during an MTP. However, these patients generally have a dramatically reduced oxygen carrying capacity. When they are pushing products in as fast as they can, they are forced to make the choice between blood and plasma. Increasing the oxygen-carrying capacity trumps the coagulation parameters every time.

Are there any facilities out there that are accepting bone marrow drawn from intraosseous lines for T&S or T&C testing? We use I-O's when peripheral access cannot be obtained in an emergency (primarily in trauma situations). There is quite a bit of data supporting the use of I-O access for infusion and transfusion. However, we recently had a situation where ED staff could not gain any peripheral access on a 2-month old trauma patient. The patient's condition was so severe, they opted to draw a few labs from the I-O line. After quite a bit of discussion and research, ED and EMS physicians have decided that bone marrow drawn from an I-O can be used for a handful of tests.....type and crossmatch being one of them. I can only find one article discussing T&C testing on bone marrow (Brickman Kr, Krupp K, Rega P, Alexander J, Guinness M. Typing ans screening of blood from intraosseous access. Ann Emerg Med. 1992 Apr;21(4):414-7.). In this study, they drew blood and bone marrow from 28 kids, performed a T&S on each pair, and compared results. The results are similar in all cases for all testing. However, only one of the Ab screens was actually positive with an HLA antibody. None of the test samples contained antibodies to blood group antigens. The researchers concluded that we could extrapolate the data from that 1 HLA antibody to assume all blood group antibodies will be detected in bone marrow. I can honestly say I have never come across this before and I am interested in any information or random thoughts from the group. First, I am not sure that I would trust and antibody screen performed on bone marrow and would probably require a physician signature before issuing blood anyway. Second, in my experience, most of the patients requiring I-O access are very young children. I am not sure any of these kids would bleed so excessively that we cannot supply the demand with O-negative units. Lastly, how would you go about validating something like this? Thanks for any comments.

Are any of you auditing massive transfusions for appropriateness? Currently, or BB medical director does a quick review of massive transfusions to ensure that coags/CBCs were drawn and she lists patient outcome, but she finds it difficult to do any more retroactively. Hospital administration has asked us to do a more comprehensive, objective review as part of our blood utilization review. We are not sure where to go with this. Also, does anyone have a separate massive transfusion protocol for pediatric patients? We are currently using our standard "adult" massive transfusion protocol for everyone, but our pediatric trauma numbers have reached a point where we probably need a policy adapted to pediatric transfusion. There is not a lot in the literature, but the physicians have suggested breaking this into either age or weight groups. Any help will be greatly appreciated.