Joanne P. Scannell

Same as Scott!

We have one of these collecting dust on the shelf. How did you get yours to validate?

Ditto!

I agree with John and Malcom. Future transfusions? Non-ABO antibodies are mostly 'extravascular' hemolysis and, as I've said before, 'Exanguination is a lot harder to treat than a delayed hemolytic transfusion reaction' so all those IgG antibodies tend to get 'ignored' during a massive transfusion situation. We actually try to hold the 'totally compatible' RBCs until the bleeding is in control/stopped. Plus, yes, there's the dilutional and immunomodulation effects of massive blood transfusion. Check the 'Instructions for Use' on your Rh-Ig product. Rh-Ig prophylaxis is usually recommended for Rh-neg patients who have received less than 20% Rh-Pos of their blood volume. Furthermore, since giving Rh-Ig to such patients will cause a mild 'delayed hemolytic' reaction (that's how it works), the IFU recommends exchange transfusion if the Rh-Pos transfusion was greater than 20%. But, as I said, I agree with John S. about all that. PS We have records in our files of patients who developed Anti-D to Apheresis Platelet transfusions ... so, it does happen. We do consider Rh-Ig per policy, but most of the time the patient is over 50yrs old so this becomes a mute/moot point.

In my opinion you are absolutely, sanely right on this! But unfortunately, 'here in the states' we have a different set of rules to follow mandated by the FDA. I always say 'Europe is ahead of us' on these things ... which is why I enjoy hearing your responses.

Where is the regulation stating that the blood can be out of temperature for 30 minutes? Since coolers can never really be validated (like someone said, cannot control opening/closing and temperature of the room/car will affect the temperature flux ... plus there's no guarantee the units are actually staying inside the cooler the whole time), and since those little temperature check labels are difficult to validate and expensive (and timely to remember to put them on during an emergency), we take the temperature of the unit of blood at the time it is returned. FDA made it very clear to us that the blood is 'in storage' if it's sent anywhere in a cooler, so the return temperature must be 1-6oC. Currently, we record the start temp and return temp of the coolers using that as the 'return temp' of the unit ... I'm seriously thinking that is not necessary/valid because the bottom line is the actual temperature of the returned unit, not the cooler. (Igloo, purchased at local stores in the spring/summer ... red and white = 1-6oC, blue and white = 20-24oC storage.) PS Tried those infrared thermometers ... cannot get them to validate. Tried the Temp-Check machine ... cannot get it to validate. Etc. So, we are still using the old fashioned 'fold it over a precooled thermometer' (precooled because it takes to long to go from room temperature to 1-6oC). If anyone has a better thermometer that will validate, please post the information so we can purchase one! Thanks!

You got it, Dr. Pepper! I was cited for this (COM 30450) during my CAP Inspection last fall! We are now performing this "QA" on all incoming RBC panels by testing them with dilute antisera (originally the ALBA-QC antisera, I may change that after reading this and another set of discussions), recording on a perpetual worksheet so it's easy to compare 'old lot to new lot'. This passed CAP approval. We don't use outdated panels so no "QA" on that end. (Yes, the quotes are there on purpose.) I better shut up now.

I totally agree! It seems they have the 'same' technical training while maybe the MTs have more of the background/academics like Biochemistry. I have found that MLTs function the same on the bench as MTs except when running into problem cases. After a few years, this can even out depending upon how much experience the MLT has had and how willing he/she is to learn the background. There are MTs that don't 'measure up' ... and, as David stated, there are SBBs that fall way short of expectations. So, even though MLT/MT/SBB don't start off 'equal', the individual proves him/herself after a while.

There's not much I can add to what has already been stated ... a learning experience, talk about it so you can be better prepared next time, etc. Except ... 1. Your supervisor dropped the ball here. As 'Quality Guy' quoted CLIA (and it should be a 'rule' regardless of who requires it), your supervisor should have a 'call me anytime and if you can't get me, call ____' with the phone numbers perpetually posted at every BB phone.As far as the policy about 'the patient has not been transfused so you do not need to repeat the workup' - yes, it may be a rational thing to do, but unless this exception is written in your policies, you are not free to skip the testing. That exception should be written in your procedures and you should have been informed of it during your training. Sounds like you were not trained to deal with 'unusual crisis' cases. Were you trained in what antibodies are truly 'clinically signficant'? Were you trained what to do if you have a crisis patient who has 'clinically significant antibodies'? ... or other issues like IgA Deficiency, Sickle Cell Protocol, etc.?2. "Remember exanguination is a lot harder to treat than a transfusion reaction." Keep in mind that it's up to the attending MD to decide if the patient can wait until all the required testing is done or not ... it's not the Blood Bank's responsibility. All the demands, threatening statements, and loud voices are not going to change that fact. The responsibilities of the BB Tech are: to inform the requesting MD of any additional risks (e.g. clinically signficant antibody, IgA Deficiency)to convey to the requesting MD the TIMING for filling the order (very important, they will change care plans based on what is said) and not burdening them with the details about 'how'.to do whatever tasks are necessary to get the safest blood out the door in a timely manner in accordance to whatever can be done in the given period of time, e.g. Group O RBCs vs Type Compatible RBCs vs crossmatched RBCs.to focus on those tasks, not worrying about what's happening in the ED or who's screaming on the phone or what MAY happen 'if'.Yes, it's all these things that help techs get through these tougher situations. You lucked out with this crisis, but as you are feeling, you need more support and more information ... get those things before this happens again.

At the time of thaw, we assign the 5 day outdate (expires at 23:59, which is very nice!) and use the 'THAWED PLASMA' versions of the Product Codes (NOT the 'Thawed NNNN' version!) I didn't see the sense of putting extra steps in the process (i.e. relabel after 24hrs). Here are the ISBT128 Codes that we use (we are 100% FP24). We used Hematrax for labeling ... I don't know where you'd get all these labels if you needed them. We also have the policy that during an emergency (or MD can't wait), we issue whatever is already thawed according to outdate, not ABO Group. Exception: We do not issue Group O Plasma to non-Group O (or unknown) patients. This helps move the inventory as well. E2619PLASMA|CP2D/XX/<=-18C|Frozen<=24hE2720Thawed PLASMA|CP2D/XX/refgE2587PLASMA|CPDA-1/XX/<=-18C|Frozen<=24hE2702Thawed PLASMA|CPDA-1/XX/refgE2555PLASMA|CPD/XX/<=-18C|Frozen <=24hE2684Thawed PLASMA|CPD/XX/refgE7644Apheresis PLASMA|ACD-A/XX/<=-18C|RT<=24h frozen<=24hE2121Thawed Apheresis PLASMA|ACD-A/XX/refgE7646Apheresis PLASMA|ACD-A/XX/<=-18C|RT<=24h frozen<=24h|1st containerE5548Thawed Apheresis PLASMA|ACD-A/XX/refg|1st containerE7648Apheresis PLASMA|ACD-A/XX/<=-18C|RT<=24h frozen<=24h|2nd containerE5549Thawed Apheresis PLASMA|ACD-A/XX/refg|2nd containerE7650Apheresis PLASMA|ACD-A/XX/<=-18C|RT<=24h frozen<=24h|3rd containerE5550Thawed Apheresis PLASMA|ACD-A/XX/refg|3rd containerE7607Apheresis PLASMA|ACD-A/XX/<=-18C|RT<=24h frozen<=24h|4th containerE6393Thawed Apheresis PLASMA|ACD-A/XX/refg|4th container

We did a 'validation' and found it took about an hour for 'just thawed' plasma to cool to below 6oC in the refrigerator. Given that, if we issue Thawed Plasma within the hour from thaw time, we put a notation 'Issued Prior to Cooling'. If it comes back, it is not expected to be less than 6oC, obviously, so here's our criteria for returning the product to inventory: (Rationale: Room Temperature stored products, e.g. Cryo, are 'good' for 6hrs after thaw.) Thawed Plasma: ‘Issued prior to Cooling’ and it is less than 6 hours from THAW time.Issued after cooling to 1-6oC and meets the same criteria as for Red Blood Cells.Platelets: Between 20- 24oC.Has not been without agitation for greater than 24 hours.

Ditto. There are just too many reasons for the ? to create a single instruction.

To add to the above (and yes, there are many versions of the 'Extensions') ... Our 'extension' is 5 days, that works for us. If a patient is being drawn earlier than 5 days or refuses to wear the BB Band, Antibody Screen is ordered and a notation is made in the chart to draw a Pretransfusion sample the morning of surgery. The result of the Antibody Screen gives us the information we need to be ready for the surgical date. BTW: We locate our specimens by the date drawn ... placed in dated racks. The computer displays the draw date so they are easy to find when needed.

EXACTLY! We shouldn't be talking 'least incompatible' anymore and we need to teach our MDs to stop talking that way, too. BTW: Since it is under the BB MD license to choose blood for patients, we do not put this burden on the ordering MD who is likely not well versed in all these BB variables. We have written protocol regarding how to deal with warm/cold panagglutinins which I won't go into on this string. But, I will say if we have to give out RBCs that are truly incompatible, it is because we are not given the time to find antigen-negative RBCs or to complete our investigative testing. If this happens, the MD is required to sign for 'Emergency Release'.

DITTO! We do the workup/tests ONLY if clinically indicated, i.e. no 'routine orders', must be ordered by the pediatrician for a reason. We do perform 'Rh-Only' on the cord blood of Rh-neg mothers because we need that test result to determine if she needs Rh-Immune Globulin.

If the DAT is positive (we use gel, but if we happen to use tube testing then yes, everything counts) AND the patient has been transfused recently (still debating the definition of 'recently'), we prepare and test an eluate. Keeping in mind that even if the entire unit were transfused, only approximately 10% of the circulating RBCs in the patient will be donor cells ... now remove those donor cells that are being destroyed ... so, ummm, why do we expect a strong positive DAT then? (We actually had a mistransfusion (nurses not doing the ID of the patient because 'they know who they are working on') where an entire unit of Group A was transfused to a Group O patient ... the DAT was negative.)

We do everything except require a Post-Transfusion specimen (hence, no post-transfusion specimen DAT, ABO/Rh Recheck, Antibody Screen repeat). 'Everything Else' = Clerical Checks, Inspection of the unit/IV tubing/IV Fluid, Documentation and Pathologist Evaluation. Yes, as some of you have stated, it is important to consider 'all those other things' that can cause adverse reactions ... it's not all about RBC Incompatibility.

Ok, so perhaps once out of temp for an hour does 'no harm', how about twice, three times, four times, etc. And I disagree with the unit staying within temperature for up to 60 minutes (were these in the days of 'whole blood'?). We take the temperature of returned units and I have yet to see one last longer than 15 minutes 'out there in the unlimited unknown environments'. Nevertheless, the very bottom line is: So what do you tell the FDA (or AABB or CAP) Inspector when they cite the 'store at 1-6oC, transport at 1-10oC' regulation?

Ditto re the reasoning. However, we don't issue RBCs until we have completed the following: If we cannot circumvent the auto antibody using other methods (which is more often than not) then we send samples to our local Red Cross Reference Lab for differential absorptions to determine if there are any underlying allo-antibodies. If negative, then there is no 'clinically signficant antibody' and we crossmatch/issue RBCs Imm Spin. If positive, we honor the identifiedantibody by selecting antigen negative RBCs but we still skip the extended crossmatch because we all know it's going to be positive no matter what we do.If the Reference Lab work is inconclusive or there is no time, we issue antigen-negative RBCs if we can. Most of our patients are known DAT Positive at the start so we perform extended typing on them if they are in a multiple transfused or building a Warm Auto situation. If 'they' are too impatient to wait for us to complete our testing = As with every other situation, we issue 'Emergency Release', requiring the statement of need and requesting MD signature. n.b. We haven't had to do this ... yet. (Did I just jinx myself?)

Ditto except the FDA forced us change the criteria to 1-6oC because the unit is considerd 'stored' not 'transported' once it has stopped moving from one place to another. (Someday they will fix this unsubstantiated dual temperature requirement.)

My condolences to his family and friends. Yes, another 'great mind' has lost it's lights. He left a great mark on the world. Thank you, George Garrity.

Ditto, once again.

Ditto!

See an earlier post here about the monolayer method ... guess that doesn't pan out the way they thought it would. And I don't know of any 'routine' Blood Bank that runs their testing using this method. In my example, since gel picks up 'everything' while the lesser sensitive method does not, we use the lesser sensitive method to perform the crossmatch. And yes, we would transfuse antigen-negative, crossmatch compatible RBCs (crossmatch compatible with Albumin). BTW: In Sunquest, we add the testing we do. XMTS for the extended crossmatch with gel (1+, Incompatible) and XALB for the extended crossmatch with 22% Albumin (0, Compatible). Since the patient has an Anti-E, the system requires the unit be typed/recorded as 'E-neg.' The 'test' %TS (Transfusion Status, part of the crossmatch battery) is the determining result - the techs final interpretation. In this case, we answer it 'OK to Transfuse' because we have determined that it is. If we answer 'Not OK to Transfuse', the system would release the unit from the patient, i.e. no unit tag, no issuing it to the floors. Of note, in the days before gel/solid phase, we probably wouldn't have seen half of these warm autos. Also, a related case of interest ... for your further amusement ... We had a 19yo female present in Sickle Cell crisis last week. She has a positive DAT (IgG only), an Auto-Anti-E (2-3+ gel and Albumin), a 'Warm Autoantibody of Undetermined Specificity' (1+gel only) aaaand is producing Anti-e (along with a history of Anti-N). Somewhere along the way in her short life, she got transfused with E-neg/e-pos RBCs (not all hospitals give antigen-neg RBCs proactively OR someone was thinking they should avoid the E antigen because it has a name). This is a prime example of why we should NOT honor Auto-'identified' antibodies because of the super exposure to the 'other' antigen. Now, this young lady will be dealing with an Anti-e the rest of her life ... through multiple transfusions (due to her Dx) and through pregnancies with an Rh-antibody. A disservice and a shame.

Ditto!