Joanne P. Scannell

Postpartum: Type and Screen (Pretransfusion specimen) upon admission to the Delivery/Labor Room. We do not repeat the Rh Type or Antibody Screen if an RhIG injection is needed but a KB is done (post-partum specimen) to determine the dose. Antenatal (28 week gestation dose): Rh Type + Antibody Screen Miscarriage/Abortion: Rh Type Emergency or Other Indications (Pregnancy): Rh Type + Antibody Screen, but we will issue RhIG if needed asap with only the Rh Type done. AS can wait. We still do the Antibody Screen because it is good documentation that will likely answer questions later, like 'Is this patient producing Anti-D or is this the RHIG injection she got a month ago?' As far as the MD is concerned, they rarely care about the AS result, e.g. we've reported an Active (as opposed to Passive) Anti-D and they still want to give the RHIG, so it's good documentation for that, too.

2+ is the only result possible as you have a mixed cell population in the tube now (patient/donor + check cells). The definition of a 3+ and 4+ is a clear background = not mixed field. And 1+ is just too weak, something is wrong.

We take the temperature of the unit when it is returned no matter how it was sent. This has become an issue here in the US and the FDA considers these units 'in storage' if they are not moving so the restriction is 1-6oC.

We use Sunquest as well. Our MTP does not drawn anything. All it does is print the order in Blood Bank. The BB Staff orders what is needed (Prepare Orders, etc.) and informs the provider IF a BB Sample is needed (often times we already have a sample). I suggest you get the order for TS out of your MTP order. We, too, put MTP on 'Downtime' protocol. Our Unit Tags are 3 parts: White Top copy, Yellow middle copy and card stock back copy. When issuing blood 'routine', the white top copy is discarded, yellow copy is kept in BB and card copy stays on the unit. For 'Downtime', the white copy stays on the Unit Tag and they use this for their dual checks, etc. Message me if you'd like more information.

No, because, unlike tube testing, you cannot spin a gel test twice. Part of the calibration of the gel test, aside from the pipetting 'exact' amounts, is 'this is how far the cells migrate through the gel beads at this speed for this period of time', i.e. second spins cannot 'count' because to do so, you have violated the requirements of the test.

Under routine circumstances, we do not prepare an eluate from positive DAT cells from a neonate because identity of the antibody can be determined from the mother's sample. Of course, if a neonate with a Positive DAT arrived without a mother, no maternal sample, or from a Group AB mother with a Negative Antibody Screen, we would likely prepare and test an eluate to aid the pediatrician with his/her care plan. (For the latter case we would request a sample from the father to determine if the mother is producing an antibody to a low incidence (aka private) antigen passed on to the infant by the father.) But, that's a whole 'nother conversation!

Given that the BB/BB Medical Director has the knowledge and background to determine transfusion safety and is responsible for blood transfusions that the MD's order, we simply wrote our policy. Yes, sometimes we get questions from the infusionists, but the BB Staff can easily answer them.

We haven't used "Post-Storage Leukoreduction" (aka Bedside Leukoreduction Filters) for many years. Search the literature and you will find that they are essentially useless. Leukoreduction is accomplished by adhesion, not size so effective reduction is dependent upon the activity of the leukocytes. Once they 'die' and breakdown during storage (a few days), they won't adhere to the filter no matter how old the unit is. In addition, the by-products of their breakdown, which cause reactions, are now released into the plasma and there are now leukocyte fragments floating in the plasma which could result in reactions caused by pulmonary filtration of these particulates or sensitization to their HLA Antigens. Bottom Line: Leukocyte reduction is effective when performed shortly after donation while the leukocytes are still viable and will adhere to the filter.

We use them and do not plan to discontinue. Too many reasons why!

WOW! CONGRATULATIONS! It's a well deserved honor!

True, David. FDA in action: We got cited during an inspection a few years ago and had to switch our Auxiliary Blood Box (aka Cooler) temperature limits from 1-10C to 1-6C. Someday, they will straighten this out (why the two limits?), but until then, we are stuck with it ... here in the US, anyway. What is the rest of the world doing?

If I remember correctly, D-neg RBCs are also LW Positive and with a strong Anti-LW, you may not see any difference. More so that this is transient.

Due to the lack of definitive guidance via actual studies (Seriously, how can that be done?), we have taken a 'logic' approach with our policy (my comments for this posting in italics) : Select Product in this order ... Indated product using shortest outdate first. (This means that plasma that is already thawed is used first, regardless of ABO Group as long as it is not Group O, see next rule.) ABO Group: ABO compatible are preferred but not essential. (And then there's a chart because it is a procedure and that has to have everything in it.) Do not issue Group O to a Non-Group O or Group Unknown patient without the consent of a pathologist. Caution: The use of ABO Incompatible plasma may cause significant hemolysis if sufficient volume is given (e.g. over 1000ml) within a 24 hour period. Notify attending physician prior to ordering and/or issuing so an assessment could be made of the risk vs need when larger volumes are anticipated. (And then instructions about how this is done and documented.)

USA here ... As for all our reagents, we test the lot when it arrives using the same protocol as the daily QC (pos + neg) to assure that it arrived satisfactory. This way, there are no surprises on the day we discard the old lot and start the new one.

We get a phone call ... very rarely does the MD have time to place orders in the HIS (EPIC) beforehand! Besides, sometimes they call for 'Emergency Release/Uncrossmatched' blood and we have a Type and Screen completed so Uncrossmatched is not appropriate. Also, we look up the patient in our LIS and determine if there is a significant reason that 'uncrossmatched' may be a higher risk than usual, e.g. clinically significant antibodies. So, that conversation is important. If Uncrossmatched is necessary, BB places the appropriate orders in the LIS (Sunquest) so they can allocate the units, etc. At the transfusion site (ED, ICU, Birthplace, etc.), the Transfusion Documentation is performed on paper (2 person ID check, etc.). The transfusion is recorded later in EPIC (there's a specific application/process for recording 'offline' activities). MD Signature is obtained and faxed to the BB after the rush is over.

No, J Series does not count for Antigen Typing because CAP has cleverly classified those results as "Ungraded". I'm not sure why they require it when it has no impact other than for us to use up valuable resources. As others have stated, they do have another series RBCAT which does 'count' and makes them more money. We should petition CAP to remove the Antigen Typing section from the J Series. I think I'll write to them ...

T&S on every delivery patient ... so, there's our Rh confirmation of the 'woman in the bed'. Post-Delivery = Fetal Cell evaluation (currently K-B Stain, that may change). Period. n.b. Unless we can prove mom is producing Anti-D, MD wants the Rh-Ig anyway, no matter what. In fact, we've had an MD want it given even when we CAN prove she's making her own Anti-D. #MDsalwaysgetwhattheywantevenifitdefieslogic

Without getting into the details, we were told by a CAP 'inspector' that we must run QC on the panel, that using the QC results from our Antigen Typing QC doesn't count. So, we started running the full panel with reagent QC Antisera upon receipt. n.b. The 'Lab General' section of CAP, which BB is bound to as well, states that QC must be done on EVERY reagent upon receipt. THEN, two years later for the next CAP, the 'inspector' tells us to 'stop this, it is non-sense!'. *^&%)W%* We didn't ... because of that 'Lab General' rule. After reading all your replies and ideas, I think I'm going to revise our 'QC' to testing a few cells (rather than all of them) with diluted antisera, Fya+b- and Fya-b-, including the Ficin panel. Keep talking ... we need a 'standard' thought about this!

We do both of the above ... 1. Test the panel against QC antisera upon receipt, as we do for all reagents; It shows the reagent survived shipment. 2. Record the Lot#/Cell# and antigen types (zygocity) of the cells used for Antigen Typing QC (heterozygous except K) ... that's periodic enough.

Gel testing will display mixed cell, so we use that method when possible. If mixed cell reactivity is seen, we cannot interpret the results (or evaluate with caution taking into account how much blood was transfused, sometimes there is a tiny amount of positive/negative cells = transfused cells).

How are you handling crossmatching when a patient's plasma contains 'Anti-D due to Rh-Immune Globulin'? This is a passively acquired, low titer Anti-D, we are issuing Rh-negative RBCs and the guidelines (AABB) are too broad ('clinically significant antibodies = extended crossmatch') so they don't seem to address this common situation. Are you performing an Extended Crossmatch or just Immediate Spin for these cases?

So, what about all the antibodies that react ONLY with homozygous cells? Very scary that you are ruling out with heterozygous cells ...

No Clinically Significant Allo-Antibodies = No Extended Crossmatch (what are you expecting up there other than the same insignificant mess, e.g. DARA, WARM AUTO?). In Sunquest, we enter the code %CINS for the Antibody Screen (%AS). This was 'invented' (by Sunquest) for this situation ... so electronic crossmatches are possible. We enter %POS for %AS only if we find 'Clinically Significant Allo-Antibodies' ... and then we do Extended Crossmatches.

I agree: If the manufacturer must state that this is a valid Fetal Cell Screen OR there must be literature/studies out there validating that a FMH greater than 30mL will always be detected in gel (ABO and Rh Typing). Has anyone out there seen such literature? Yes, annoying when facts are twisted and general statements are made that don't reflect the truth of the matter. There are lots of them out there. Grrr, too.

We built a 'test' in Sunquest that is simply 'allocate (using barcode reader), press 'OK', sign-out, tag the unit, hand it over'. The advantages are computer assisted QA only when appropriate (e.g. trying to allocate A POS to an untyped patient), no handwriting and accurate recordkeeping.