Joanne P. Scannell

Note: If STORED, then it must be maintained at 1-6. So you need to define: Storage: If it is sitting somewhere in a refrigerator or cooler for x period of time. Transport: If it is, ummm, in transport, e.g. being taken from the BB to a floor without being stored. For Transport: We use a precooled thermometer and fold the returned unit around it to determine the temperature. If over 10C, it is discarded. For external storage (we use coolers and ice), we take the temperature of the inside of the cooler. We are looking at other methods for this and checking out a digital thermometer with a probe that will record min/max temperatures. Very interested to hear how those infrared thermometers are working out!

Please note: The AABB rule was changed from 72 hours to 3 days (Date of draw being Day 0) several years ago.

Adding in my 2 cents ... I often find myself saying 'Well, the FDA APPROVED this!', with and incredulous shrug on my shoulders. Oh, do keep in mind that there is NO perfect or near perfect software out there for Blood Bank so just do the best you can with what you've got and put in 'checks and balances' for the areas where there aren't any. One of our biggest pet peeves is that there are way too many times that multiple techs cannot access the same patient in various BB applications and this is VERY frustrating (if not dangerous) during emergencies. Example: You cannot allocate FFP (BOP) and/or crossmatch (BOP using a different Accession #) while someone is issuing blood (BPI). Imagine if McDonald's software worked that way! Another example of why I believe their software engineers don't talk to each other and that whoever is the project manager never worked in a real live Blood Bank/Transfusion Service.

Antenatal/Prenatal: We perform Rh Only and Antibody Screen.

Good news! Let me clarify that statement, 'reference labs that I have had experiences with'. Thank you!

We use Sunquest. XM (Crossmatch) = I.S. (Immediate Spin) + TS (Transfusion Status) So, when a unit is allocated, this is what we see as 'basic required'. I.S. - we put in the result. If positive due to cold agglutinin, interpretation is 'CMBT = Compatible by Blood Type'. If not done, result = ND, interpretation = ND. This is defined as acceptable in the maintenance. IF more testing is required, e.g. Gel Crossmatch, then that is added as a test to the units. I have built 'tests', XMTS, XALB, XNP, etc. for all the 'complete crossmatches' we do, MTS, ALBumin, No Potentiator, etc. TS is resulted 'Ok' or Not Ok' ... but you knew that. Yes, FDA requires I.S. crossmatch. This was originally set up to catch ABO Incompatibility/Mistakes (the only other reasons being cold agglutinin or rouleaux, neither of which are clinically significant). In today's world of rechecks, this is just redundant ... I'm hoping the FDA will catch up someday.

Woah. First, if you are detecting Anti-M in gel, it may be simply because gel is acidic (and if you remember from years ago, acidifying the serum was a way of enhancing Anti-M). To test if this is the case, test the patients plasma vs M-pos cells using one of the traditional tube testing procedures. We see this a lot ... perhaps we would have all those years before gel if we used acidified serum for routine testing. Second, Anti-M is not considered clinically significant for HDN, therfore, we don't run titers on this antibody. (Not all IgG antibodies cause HDN for various reasons ... that's a whole 'nother conversation!) Even if we did, there is no answer to your question about what titer is to be considered significant for Anti-M because there is no strong literature to support it. Furthermore, it's not the particular value of the titer, it's the significant movement of the titer (i.e. greater than one tube change) during the pregnancy (common practice is to test every month) that provides one of the clues that there may be a problem brewing that requires a closer look (e.g. amniotic tap). If the titer does not move, it is likely the child is negative for the corresponding antigen. Yes, we all know there are exceptions, etc. I'm just stating general practice here. nb. Whenever we identify an antibody that is clinically significant for HDN (we are using gel), before preparing the titer dilutions, we test the patient's plasma vs antigen positive cells using tube technique which is essentially the 'neat' (or 0) tube of the standard titer (= tube testing, dilute with saline, no enhancement, see AABB Technical Manual, literature is based on this method). If it is negative, there is no titer and the result is reported with 'Below Titration' (or one could say 'less than 2'). Why are you titering IgM activity? IgM does not pass through the placenta. Different for transfusion: If we find Anti-M, we test again prewarmed. If prewarmed test is negative, the result is 'Cold Agglutinin: Anti-M' and we transfuse just as any other cold agglutinin, i.e. use a blood warmer, period. btw: Patients who are producing Anti-M but type 'M-positive' may actually be 'Mg-positive'. Mg is a common antigen that reacts with some reagent 'Anti-M'. Hence, it is not fruitful to type these patients for M when you know you are likely to get a positive result ... so don't bother. We don't even purchase Anti-M anymore. That's not to say patients cannot develop an Auto-Anti-M ... I have a great case I call 'The Purple Lady'. Careful ... Reference Labs test for and report EVERYTHING, significant or not. Just about every report I have from our reference lab states 'Cold Antibody at 4oC'. Yes, we are forced to pay them to test for and say that even though we don't care what happens at 4oC and most human beings have some Anti-I activity at that temperature anyway. It is up to the Medical Director of the Transfusion Service to determine what is clinically significant for any given case. e.g. our 'Purple Lady' and a clinically significant COLD IgM Auto-Anti-M. Cool case ... no pun intended!

I believe the 'second specimen' idea is totally out of control and definitely NOT the way to security. If we have a history of ABO/Rh from a BB Banded specimen, is that not the first specimen? If we demand 2 specimens, what is the guarantee that the same erroneous patient isn't drawn the second time? And you all know that nursing will find a way to circumvent our 'demands'. There is plenty of evidence to suppor this statement from 'drawing 2 specimens at the same time and holding the second tube to send to the BB later' to 'drawing the lady in the bed near the window in Room x'. We even had the wrong patient drawn and banded during a training session! Don't think that phlebotomist stationed on that floor wouldn't simple go 'redraw' that same patient when BB requests their second specimen. Then there's the internal issues ... some collegues report that they just go into Chemistry or Hemo to find another specimen on that patient to perform a second blood type on. This is not comforting. And what do you do if the 'second specimen' doesn't match the first specimen? A third as a tie-breaker? Without BB Bands attached at the time of draw, who really knows who is drawn? Hospital admitting DOES make mistakes and change/update the hospital bands ... what security is that? We had a situation where the two ladies in one room were wearing identical bands. (At least with separate BB Bands, the wrong patient won't get transfused.) So, you cannot convince me that simply '2 specimens' is a safe route. Error potential lies in several places ... all must be addressed to form a secure process: At phlebotomy - the patient wearing the BB Band is the patient 'in the tube' ... even through hospital ID band errors, name revisions, MR# changes, DoB changes, this fact remains the same. (And let's not forget 'Unidentified Patient' ... if you have an emergency room, you have these patients now and then.) In the Blood Bank - processes must be in place to prevent mixups on the bench ... that includes, but not limited to, 'no transfusion until a second tech sits down and repeats the ABO/Rh on that sample'. At Transfusion - nursing cannot transfuse unless they match the BB Band numbers. And 'No BB Band = No Transfusion'. How about the Group O patient we had who couldn't get a transfusion of Group A RBCs because she wasn't wearing the BB Band? The lady in the next room was wearing it ... all done with proper hospital identification bands! Some patients just don't notice their bands have someone else's name on them. Without the BB Band, everything looked perfect and Ms. Group O would have recieved that Group A unit. Two specimens would not have prevented this transfusion, a 'missing' BB Band did. Need more stories?

Ditto. Type and Screen = we Type and Screen and we wait for orders to actually transfuse. As long as we can promise a 5-10 min 'ready to issue', we wait. If the patient has antibodies that would prevent that, we do set up the units ahead of time for surgeries (not routines). Nb. To prevent last minute surprises (e.g. Screen is negative but I.S. XM is positive because of rouleaux or cold agglutinin and now we have to spend some time working that out), we run a tube test I.S. with pooled O cells (from the 3 screening cells) with every Type and Screen. This gives us the preview we need. Blood Bank Hold = No testing, we just log it in (it's a 'test order' so it gets tracked as such, i.e. we can 'see' it in the LIS) and keep in in the refrigerator. n.b. We do check our records and if we have a record of problems, we notify the attending. This gives us a 'head start' if needed.

I believe gel detects more Anti-M's because the medium is more acidic than reagents used in tube testing. Some of you may remember the old 'acidified serum' procedures ... we actually used to look for these things on purpose! As far as cold agglutinins, just get your cards in that heating block as quickly as possible! Besides, they are easily identified ... that mixed cell reactivity gives it away quite clearly. So, in gel ... being bothered by those pesky cold agglutinins is just a 'fond' memory.

Ditto. I must add that the second ABO/Rh is a recheck using front type only AND is performed by a second tech. (ALL techs are trainable for this, no matter what department they work in!) I don't mean to be pitting one tech against another but in addition to having the ABO/Rh confirmed, psychology has it's effects, i.e. Tech 1: No one wants to be proven wrong. Tech 2: Everyone wants to prove you wrong. Sp each is especially careful.

I recommend you opt for the Pink tops: 1) They have a 'dry' EDTA (sprayed along the inside of the tube) rather than a liquid EDTA. Hemo machines calculate for this dilution factor, Blood Banks cannot. (I'm surprised this isn't obvious ... to use an undiluted samples.) 2) They are a different color than Hematology samples so they are easily sorted (if you are doing that manually, etc.) I believe the vendor (we use BD) can provide you with some literature if you feel you need it (seems pretty self-explainatory to me based on the 'dry' vs 'wet' EDTA). Note: To decrease the possibility of 'artifact' in MTS, invert the tubes (not gently but not vigorously) a few times just before you put them into the centrifuge. Not sure why, but it works!

I tell people that's why I'm not a doctor ...

YES, HELMER!!! No doubts, no regrets!

See what THEY have done to us!? Ok, to get really crazy ... (and I do hope you don't take this too seriously!) How many of you wear gloves while crossmatching? 1...2...3... yah, it's a regulation. How many of you put the unit of blood on the bench when removing the segment while you are wearing these gloves because you are going to be performing the test? 1...2...3... yah, don't we all? So, now isn't that unit of blood that was placed on the bench (considered a contaminated bench) now contaminated? It goes back in the refrigerator to wait to be issued. Then, miraculously, as it passes out of the blood bank, it becomes 'ok' as it hangs in the patient's room. Does everyone who touches this unit wear gloves to protect themselves from this now contaminated unit of blood? And how about in the OR ... this now contaminated unit of blood is being passed around in a sterile environment, contaminating the whole staff! Yikes! Hmmm ... maybe we ought to wash the units down with antiseptic before we issue them ... But then, then, has anyone done any testing to see what the effects are through the plastic? (a la label glue?) I'm wondering how many people have died because we didn't wear gloves while issuing those millions of units of blood over the past 50 years or so. How many of you wash your money before you touch it?

We validated Ortho's Anti-C3b/d in gel. Very simple: 12.5 mcg patient's 4% cell suspension (in Diluent-2) plus 25mcg Anti-C3b/d in a buffer card. For patient control, add 12.5mcg patient cells into another well without adding the Anti-C3b/d. We do make up our own Complement Coated cells using an old Red Cross Procedure Manual. It's easy and it works! For QC, we run the Complement Coated Cells each morning as a positive control. We run a reagent cell as a negative control.

Pharmacy handles them ... they are pharmaceuticals! We don't need to determine compatibility and they have NDC numbers ... they are handled, billed and adverse reaction reported as pharmaceuticals, not Blood Components. Following the argument, the have blood factors in them ... why doesn't the Chemistry department distribute insulin then?

I believe that whoever wrote the 'Store at 1-6, Transport at 1-10' rule was a bit narrow sighted. Obvious storage is in our refrigerators, but what about the boxes we 'store' the blood in while they are waiting (sometimes for hours!) to be loaded onto a truck? Are they 'in storage' or 'in transport'? When they are IN the truck,we clearly see them as 'in transport'. So, I guess the criteria is based on is really 'is it in a moving state?'. Given that, if the cooler is sitting on the ground, it must remain between 1-6oC. If it is being carried somewhere, it can go up to 10oC. (Ummm, what temp check stickers are we using, 1-6 or 1-10 for these?) Are we all nuts or what!? Whatever ... the rule should be rewritten for clarity's sake: e.g. RBC's must be maintained at 1-6oC. However, if allowed to warm up to 10oC for longer than X minutes (hours?), then the outdate must be amended to ____ (24hrs?). If allowed to warm up greater than 10oC, it must be discarded. (Interesting that the current rule states we can't reissue it ... why doesn't it state we must discard it? Do YOU store such units in quarantine until they outdate? We don't either.) This is how it is stated for bones ... it's very clear what to do when. So, if there is anyone out there who has any control over writing the FDA regulations, can you bring this up at your next meeting please?

Check out Wescott Laboratory Solutions ... they carry various Biohit Pipettors and can help you pick one out.

Got one along that line of thinking! We were told by a resident to just give him WASHED cells if we couldn't find compatible units (the patient had a few antibodies). Ahh, if it were only that simple!

Seriously, is every tech reading and absorbing every word in the WHOLE set of procedures? Realistically, in a 'read it all once a year' setting, they are skimming and signing just to get the task done. I don't see that as effective. Do you review the driver's license manual every year? Or the manual for your TV set? etc. etc. etc.

Too much work ... again. New procedure or revisions: Mini copy is printed and put in a 'New Procedure/Revised Procedure' notebook. Techs are instructed to review and sign off on a review sheet during or prior to their next rotation/shift in BB. btw: For revisions, I highlight the area revised so they don't miss it. Other than that, why review? Seriously, that's a LOT of data to absorb in one sitting/short period of time! The SOP's are there on the shelf for reference if the techs feel they don't have it memorized (eg 'haven't done this for months!') or a question. n.b. If there are errors where the tech did not follow the SOP, part of the corrective action is to have the tech re-review the procedure (with appropriate documentation). +n.b. Annual quizzes (if I choose that route for competency assessment) include questions about those obscure details we tend to forget or info that the techs may have forgotten are there in the SOP's or issues that have come up during the year. +n.b. New employees make the trek through the SOP and sign off on them as they are 'learned'. Keeping the techs in the 'know what you don't know' zone is a perpetual task... and it's got to be proactive ... not a 'once a year sit down and run your fingers through the pages, remember it all for the next year, and hand me the sign-off sheet when you are done'. CAP, etc. requires that the manager (or such) review each procedure at least annually ... this is to make sure the procedures are error free and up-to-date ... THAT makes sense! (I do one section per month so I can focus on the details ...)

Love it! I do similar for those 'annual competencies' but I like this 'spot check' idea! btw: I use Kudos bars for 'good deeds done', aka 'Kudos to ...' Good for you!

Way too much work here! Yes, Ortho has issued an excellent 'Interpretation Guide' for MTS. Get one and use it. Rouleaux shows up in gel as either haze or mixed-cell (see the pictures). Haze = rouleaux (there's nothing else significant that causes this picture). Period. Yes, in tube testing it's very hard to tell rouleaux from weak agglutination unless you use the microscope and/or saline replacement. This is not the case in gel. Leave it, you are done. It's rouleaux, get over it and move on. Mixed-cell could be a cold agglutinin or rouleaux (yes, mixed-cell population, too, but it's not so for reagent rbcs, most donors, etc. so let's set that aside for this discussion because it doesn't apply to antibody screen/panel). To tell the difference, we run the patient's plasma IS/RT with pooled O cells and determine if we see rouleaux (yeah, the microcope!) or true agglutination. If it's a cold agglutinin ... use a blood warmer. There's no other information we need for the purposes of transfusion. Done.

Ok, we got an order the other day for '1 unit Platelets 'Freezing'. Took as a few phone calls to find out that this was a direct order typed into the hospital ordering system by a RESIDENT ... what she really wanted was a Plateletpheresis unit. Another example of why they call it 'practicing medicine', I guess.