Joanne P. Scannell

Ael? Or am I dating myself?  I agree with Malcolm, for transfusion purposes, it doesn't matter what you call it.
And ADsorption vs ABsorbtion ... I always looked at it this way: It depends on whether you are looking at the cell or the plasma.  Antibodies are Absorbed from Plasma and Adsorbed onto RBCs.

Ael? Or am I dating myself?  I agree with Malcolm, for transfusion purposes, it doesn't matter what you call it.
And ADsorption vs ABsorbtion ... I always looked at it this way: It depends on whether you are looking at the cell or the plasma.  Antibodies are Absorbed from Plasma and Adsorbed onto RBCs.

Although I agree that treating a transfusion reaction is a lot easier than treating exsanguination, in this small hospital setting where they have only 6 units of blood to begin with, I don't think it would go so well to switch to incompatible after only 4u transfused.
I'm with the group suggesting the hospital switch to stocking 4 O Pos + 2 O Neg RBCs.  It is possible, don't let your provider tell you otherwise.

Ditto.  We haven't 'split' a unit for a non-neonate for over 20 years!
I agree with the above ... we'll just state what we do if we ever do get an MD who requests a split unit.  I'd only add that the usual approach is for the MD to instruct the infusionist to 'Transfuse over 4 hrs.'  vs the usual transfusion rate of 1.5 - 2 hrs.
Eventually, hopefully, the CAP Checklist Team get the message that splitting the unit is not the only answer and shouldn't be unless it's done often enough to maintain competency, etc.

Ditto.  We haven't 'split' a unit for a non-neonate for over 20 years!
I agree with the above ... we'll just state what we do if we ever do get an MD who requests a split unit.  I'd only add that the usual approach is for the MD to instruct the infusionist to 'Transfuse over 4 hrs.'  vs the usual transfusion rate of 1.5 - 2 hrs.
Eventually, hopefully, the CAP Checklist Team get the message that splitting the unit is not the only answer and shouldn't be unless it's done often enough to maintain competency, etc.

Ditto.  We haven't 'split' a unit for a non-neonate for over 20 years!
I agree with the above ... we'll just state what we do if we ever do get an MD who requests a split unit.  I'd only add that the usual approach is for the MD to instruct the infusionist to 'Transfuse over 4 hrs.'  vs the usual transfusion rate of 1.5 - 2 hrs.
Eventually, hopefully, the CAP Checklist Team get the message that splitting the unit is not the only answer and shouldn't be unless it's done often enough to maintain competency, etc.

Devil's Advocate Asks:  If we establish that the reason for the reactions in the backtype are due to cold agglutinin(s), why are we pre-warming ABO tests?   Pre-warm = 37C reacting antibodies.  If this is a valid alternative to RT/I.S. Crossmatch, then shouldn't we be performing an Extended Crossmatch (37C to AHG) to look for the IGG versions of the ABO Antibodies?
Simple Answer: Immediate Spin Crossmatch:  If due to cold agglutinin (other than ABO) = Compatible by Blood Type.

Devil's Advocate Asks:  If we establish that the reason for the reactions in the backtype are due to cold agglutinin(s), why are we pre-warming ABO tests?   Pre-warm = 37C reacting antibodies.  If this is a valid alternative to RT/I.S. Crossmatch, then shouldn't we be performing an Extended Crossmatch (37C to AHG) to look for the IGG versions of the ABO Antibodies?
Simple Answer: Immediate Spin Crossmatch:  If due to cold agglutinin (other than ABO) = Compatible by Blood Type.

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.

Thanks ELondon.
Could I just say again, even if the Reference Laboratory does detect an antibody (or more than one, come to that), it is not a particularly abnormal thing in pregnancy, but it does not mean for one minute that the pregnancy will be affected; Mother Nature has seen to that.
There is another Blood Group System named Lewis.  The antigens within this system are soluble in the plasma part of your blood, and are adsorbed onto the red cells from the plasma (they are not intrinsic to the red cell membrane).  During pregnancy, the concentration of plasma lipoproteins (fatty proteins in the plasma) can increase enormously (about four-fold).  These plasma lipoproteins "mop up" the soluble Lewis antigens, and a pregnant woman, who would normally be, for example, Le(a-b+), can become Le(a-b-), and may even, temporarily, produce antibodies against the Lewis antigens (an individual hardly ever produces antibodies against an antigen that they express - but strange things happen in pregnancy!).  In addition, ALL babies are born as Le(a-b-), so any Lewis antigens Mum produces will NOT affect the baby!
There are many, many other antibody specificities that will not affect the pregnancy at all.
Now, I should say two things.  Firstly, I cannot say, from a distance, what is the antibody in your plasma (that can only be done by the laboratories at the Hospital and the Reference Laboratory, but it does not sound at all serious).  Secondly, i am what is called a Biomedical Scientist, not a doctor, and so I am, by Law, not allowed to diagnose (as far as I know, neither is the midwife), and this is why I am so glad that you are going to see an Obstetrician, who, I hope, will be able to reassure you even more.
Mean while, sleep easier, and enjoy your pregnancy!

PLEASE do not worry.  Your midwife is COMPLETELY wrong, and really should not comment about something she patently does NOT understand, and about which she has a pitiful amount of knowledge.  She should never have answered your questions with her lack of knowledge, but should have left it to your Obstetrician.
I note that you are a fellow "Brit"!
Within the British population, the percentage of people who have the R1R1 type (which is a type within the Rh Blood Group System) is 16%.  Also within the British population, the K- type (which is part of the Kell Blood Group System) is 91%.  What that means is that 91% of 16% of the British population is R1R1, K-, or, give or take, a few decimal points, 15% of the British population (about an eighth of the British population).  On Friday, 19th October 2018, the British population was measured as 66,690,116!  Let's call that 16.5 million in round numbers.  This means that, give or take, 9, 975, 000 in Britain are R1R1, K-.  Now, admittedly, your midwife will only be looking after women, but, even then, that means 4, 987, 500 women will have the same Rh type and K type as you!  How your midwife has only come across your "rare" type four other times in her career, is beyond belief (and I genuinely mean BEYOND belief), unless, as I say, her knowledge of blood groups and blood group serology is incredibly poor, and I repeat, she should NEVER have worried you like this.  Just in case you think that I do not know what I am talking about, I have worked in the field of blood transfusion/blood group serology for 43 years, have been an internationally invited lecturer and am the Chief Examiner in Transfusion Science for the Institute of Biomedical Science in the UK, and am a co-author of the British Society of Haematology's Guidelines for Blood Grouping and Antibody Testing in Pregnancy.  I don't write that to "blow my own trumpet", as it were, but to try to reassure you that I actually do know what I am talking about.
I should warn you that "consulting Dr Google" is equally as useless as listening to your midwife.
You should really relax.  YES, it is possible for you to produce red cell antibodies during your first pregnancy, but it is INCREDIBLY RARE.  It is even more rare for such an antibody to cause any problems in a first pregnancy.
I notice that the report from the Blood Bank was that they detected WEAK reactions with 26 of 30 panel cells, but they could not identify a specificity.  They have requested three further samples of blood to send to the Reference Laboratory.  Again, to give you some comfort, I hope, I ran a Reference Laboratory in London for 16 years before I retired in 2016, and we saw, quite literally hundreds of cases like yours.
For a red cell antibody to cause any problems within you pregnancy, it would have to have a titre of 32 or above (this means that it would still be detectable when it has been diluted THIRTY TWO times).  I can assure you that the mere fact that the Blood Bank reports weak reactions means that there is ZERO chance that the titre will be 32 or above.  If a Hospital Blood Bank, however big or famous the hospital may be, cannot identify an antibody, it is almost universal practice that samples will be sent to a Reference Laboratory for further testing - AGAIN, DO NOT WORRY ABOUT THIS.
There are many, many red cell antibodies that are clinically insignificant, both in terms of transfusion reactions and haemolytic disease of the foetus and newborn (which is what your midwife has left you worried about).
I KNOW it is difficult, but PLEASE do not worry.  PLEASE take no notice whatsoever of your midwife on this matter (I am sure she is an excellent midwife, but she is patently no expert in the field of blood groups), but DO talk to your Obstetrician, who, I hope, will have talked to your hospital's Haematology Consultant, who, in turn, will have spoken to the Consultant in Charge of the Reference Laboratory, and I am sure that they will echo my opinion that there is NOTHING to worry about.
Oh, and lastly, I am R1R1, K- myself!!!!!!!!!!!!!

It MUST be remembered that not all antibodies react by all techniques, but, equally,it MUST be remembered that not all antibodies are clinically significant.
I remember way back in the 1980's, when I was working at a hospital in Croydon, Surrey, UK, we had an anti-S that we could only detect by tube technique.  We sent this around to a whole bunch of other hospitals, who also used a mixture of techniques.  Not one of them could detect the antibody by either microplate techniques or column agglutination techniques, both thought to be more sensitive than tube techniques, but all of those who also used tube techniques were able to detect the anti-S.
I also remember having an anti-E that did not react with enzyme-treated red cells, but only reacted by IAT with untreated red cells.  This was confirmed by the International Blood Group Reference Laboratory.
Antibodies do not read books, particularly text books!
Antibodies are only clinically significant if they react strictly at 37oC, and even then, not all are clinically significant.  Think about the antibodies against antigens in either the Knops or Chido/Rodgers Blood Group Systems.

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.

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.

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.)  
 
 
 

We are using the ELUclear Kit (Hemo bioscience) and the 0.8% reagent red cells (Ortho/J&J, whoever they are now) and have no problems ... and we do a lot of eluate preps/testing.

Neither have I, and this is something that has worried me from the start of this thread.

We also had the same problem some years ago. We now routinely spin on receipt (could be small trapped bubbles due to disturbance in transport) and store upright - Problem solved.
Also where is the authority to spin a second time when reading coming from??? Never seen that in the literature. -

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!

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!

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.

In the US we have been doing what you say is going to be the new policy for many years, except we only would do a DAT if the autocontrol was positive.  I think that approach is pretty common.  Orthos' panel A is for the ijnitial assessment.  Most of the time, you will have a pretty good idea what you are dealing with with those results.  Then, going by the 3 x 3 rule, w use other panels for rule-outs / rule-ins.  Also, if there is no history, we antigen-type the patient for those antibodies that are being made.
Scott

Hi klsmith,
I am now retired from the Reference Laboratory, but there is NO WAY that we would just have used red cell samples that we knew were going to be negative (or expected to be negative); indeed, if we suspected a mixture of antibodies, we would set up a cell sample for each suspected specificity, but one which are negative for the other antigen(s).  For example, if we suspected a mixture of anti-D+C+E, we would set up a panel that included an example of an Ro, an r'r and an r", as well as a selection of rr cells, expressing all of the other clinically significant antigens.  In the UK, we believe that any specificity should be "proved" with two red cell samples expressing the antigen giving positive reactions, and that, wherever possible, a specificity should be "proved" to be missing with two red cell samples expressing the antigens giving negative reactions.
I attach the antibody algorithm I put together for NHSBT Reference Laboratories some years ago now.
Antibody algorithm..ppt