[Why not refreeze thawed plasma?]

From a pure common sense standpoint; the same reason you can't refreeze thawed meat, cooked or not. 

[Glass Tiles/Ceramic Tiles]

I train high school students on ABO grouping using leftover bacti cards from kits like strep or influenza.  They are disposable and easy to come by.  Works just fine.

[ECHO with Manual Gel as backup]

We have the ECHO and use Gel only as backup.  If we want to run something in tube, the 0.8% cell suspension must be concentrated to approx 3% for tube testing.  That is rarely done here.  We would send it to our reference lab for further investigation.

[Sensoscientific wireless temperature monitoring]

_{Just started using TempTracker here and it's nice.  There was a acclimation period where we got a lot of erroneous high/low alarms.  We still chart and physically record temps daily but, maybe soon, we will eliminate that.  Alarms still active too,}

[Frequency of ABO recipient typing prior to FFP transfusion.]

One blood type per admission.  We've had our admitting department mis-register a patient leading to a transfusion of incompatible FFP. 

[Local newspaper publishes damning report against blood transfusion]

Blood transfusions are a risky procedure, but less so than exsanguinating.  Our blood supply is as safe as the person donating it and transfusions are as safe as the policies and knowledge of the staff administering it.  This article could have been written with less incindiary and made to be more informative.

[Bit of a rant....]

Don't even get me started!     The things i've had to deal with over the last 5 years have left me wondering how have we remained acredited.  I have had to learn how to apply the serenity prayer on a daily basis.  It's especially unnerving when the incompetence comes from the department manager.   To have to daily correct your managers errors and oversights, while not appearing to challenge their authority is quite an interesting environment.

 

[Operating Room Risk Reduction Plan for Mistransfusion]

It seems that the most adamant protestsors to safety measures are the ones who are most prone to making the very mistakes that lead to the policy changes: ER and OR!  They never have time to do things right or careful.

[Echo users.]

We do not use the Pediatric reflex nor do we reflex weak D testing.  We have disabled all Reflex testing at our facility.  We do not perform weak D testing at our facility at all (with rare occasion to confirm a blood type on a unit from our supplier labeled rh Pos when we get rh negative initially).

 

We are a 175 bed, predominately geriatric hospital that has absolutely no pediatric or maternal patients. 

 

We do export our results to MEDITECH 5.6.6.  The ABORH exports but not the SCREEN since the reactions must be entered in a secondary result screen.

[ABO/Rh confirmation labels--necessary??]

If someone mistakenly places an unconfirmed unit on the confirmed shelf and you are on downtime, there is a possibility of an unconfirmed unit getting transfused.  

I would like to do away with all this extra work too but that is a little scary.

Not to be argumentative but we blood bankers tend to be overly paranoid.  What is the percentage of units you recieve from your supplier that are incorrectly labeled aborh?  How often does units get mistakenly placed on the confirmed shelf, picked up by a tech, crossmatched and released for transfusion, all before your LIS is back up?  I think if you really look at the odds of a negative outcome situation that would be averted by the use of a sticker, you'd see that your fears are really unwarranted.  Risk is never truly mitigated completely.

[DAT on every hematology work up!?!]

My experience has been that a DAT is a normal part of a hematology workup.  Our Hematologist order a DAT as part of their anemia and auto immune disorders for new consults.

[Anti-M quandry Looking for feedback]

From a strictly practical approach, I don't understand the quandry.  Since it's reacting at 37 degrees, just crossmatch using M ag negative units and move on.  Why was all the additional testing necessary?

[Antibodies Identified at Another Facility]

When talking to patients also be sensitive to their situation.  Many, many years ago as a young BB'er I found an anti-D in a 30 year old woman which, I thought, was likely a passive anti-D.  According to our policy I went to her room to collect a history.  She had a couple of visitors but I went ahead and asked about recent pregnancies or situations that might have called for RhIg injection.  She denied everything.  I returned to the lab ready to document it as an active sensitization.  Shortly thereafter her nurse called and said the patient wanted to talk to me.  I returned to her room and found her visitors gone.  She admitted to a recent pregnancy, it's termination and subsequent dose of RhIG.  The visitors present at my earlier visit were her parents and were unaware of the situation, so she had lied.

That taught me to be a little more discrete with my interrogations, and reinforced the realization of the value of patient interaction.

In the States, we are constantly trained on the matter of HIPPA security.  If, on rare instances, I go to speak to a patient directly, the first thing I ask is are you comfortable discussing your care with visitors in the room.  I don't begin any discussion if they answer no.  That may not prevent this type of issue mentioned above but it covers my butt from and inadvertant HIPPA violation.

[Antibodies Identified at Another Facility]

 

 

I would antigen type the patient. If K negative, we would transfuse with K neg units (easy enough to find them). We would probably add the Anti-K to his account with a note that it came from the patient.

A couple years ago we found an Anti-E and Anti-c on a patient and prepared compatible units. When we were getting ready to issue them, the nurse called and said the patient would like to speak with us. I went up and she told me that she had "antibodies, but doesn't know what that means, and she had a horrible reaction many years ago". She insisted I call the hospital where she received the blood, even after I assured her that we found the antibodies. I called the hospital and they had Anti-E, c, and Jka. WHOA!!! Ever since that lovely lady was insistent, I listen to patients.

For reasons such as this, whenever I have a positive antibody screen on a new patient, I call the floor and ask if the patient has been transfused before and, if so, where.  I then call that facility and get their history.  In transfusion medicine, we have to be investigators who are willing to turn over every stone. 

[Hazy reactions in Ortho Gel Cards]

From my experience if I understand your description of "hazy reactions" correctly, is how Anti-M (IgM) often react.  A lot of the Anti-M's that I get are not your normal gel positive reaction.  Rather, they are a fuzziness up the gel column, usually on the Homozygous cells only.  I think I have seen this with some other colds as well.

[Historical Record Check - How to prevent errors from misregistration?]

Very common problem.  The best we've found to do is to search using Social Security number or Name, DOB.  It is not just a blood bank problem.  Allergies and Special nursing notes are attached to medical records as well.  If that patient is given a new MRN, Nursing staff won't have those important warnings.  I see this problem magnified with a national medical database.  Imagine how many times a person can be duplicated on a nationwide scale.

[what is the frequency of the C, E antigens on D negative red blood cells?]

Ruling out with only heterozygous cells (with few exceptions, e.g. Anti-K) is risky business.  I don't allow my staff to do that and I don't recommend it.

• There are plenty of examples of antibodies that react with homozygous cells only (due to sensitivity of the test and concentration of the antibody) ... so you will get a negative result with heterozygous cells whether you run 1, 3 or 999 of them.
• Sure, if you miss such an antibody, it is weak and will likely not cause a noticeable 'reaction' ... you'll likely see it better next time around.  Oooor maybe you won't, some patients never pass that threshold and continue to react with only homozygous cells ... so you'll just keep wondering why the patient keeps coming back for more transfusions and perhaps rising chemistries, positive DAT, etc.

The 3+3 rule is often misinterpreted/simplfied.  In reality, we 'rule out' with 1 cell every time an antibody screen is deemed negative (e.g.. no antibody identification is performed, 2 more negative cells for each antigen is not sought, etc.).  This is ok as long as you are testing using homozygous cells for 'all', i.e. most 3-cell screening kits. 

 

As far as finding 'D-neg, C-pos and/or E-pos' reagent cells to determine if the Anti-D is masking Anti-C and/or Anti-E ... good luck!  Those are rare cells not seen often enough on panels.

 

Bottom line:  If patient is producing Anti-D (i.e. not passively acquired from a 'pure and only Anti-D' injection), we rule out Anti-C and/or Anti-E only if

a) we can locate the cells to do so ('never' happens)

or

the patient is positive for C and/or E respectively. 

If we cannot, the report is "Anti-D, Cannot rule out Anti-C and Anti-E" (whichever applies, most often they both apply). 

 

To address the original question:

Yes, we type Rh-neg (D-neg) RBCs for C and/or E as applicable.

Yes, we do perform an extended crossmatch on any sample with 'clinically significant antibodies' (including Anti-D) if for no other reason than to eliminate 'wondering if there is anything else' and/or 'mistakes'.

 

Does anyone remember 'the old days' when we used to use a reagent containing Anti-D, -C, and -E (Anti-DCE) instead of just Anti-D?  Donor units that were positive with this mixture were labeled 'Rh-Pos' ... maybe we should go back to that practice.  Hmmm ... thoughts?

While I agree with your statement about ruling out with 1 heterozygous cell is risky business, In this scenario, the risk is minimal.  If we were talking about Jka, that would be another story!

 

The fact that C and E will be absent on rh negative units at least 99% of the time and the unit is required to be crossmatch compatible through AHG mitigates whatever risk there might be.  Ruling out C and E with 1 r'r and r"r cell in the presence of Anti-D is time efficient, cost effective and safe.

 

The real issue here was the tech did not perform an AHG crossmatch.  That is a competency issue.

[what is the frequency of the C, E antigens on D negative red blood cells?]

Hello again,

What is the frequency of the C, E antigens on D negative red blood cells? We have a male patient who received O Positive uncrossmatched emergency units in 2011. Now he is showing an Anti-D antibody. The tech who performed the crossmatches yesterday did only an immediate spin with an O Negative donor unit without ruling out Anti-C or Anti-E because the panocell results looked like Anti-D. The units were issued early this morning before a QA could be performed. I phenotyped the patient's initial T&S cells obtained before he received packed cells. Patient is type O Rh D=, C=, E= . What would be the probability of this patient forming either Anti-C and/or Anti-E as well? My ARC reference lab pathologist is on vacation, but I sent her an email asking this. Unfortunately, the patient is inhouse and symptomatic. Any help would be appreciated since I am new to BB mommahood.

The frequency is low, I believe less than 1%.  Some labs, like mine only require 1 heterozygous C+ and E+ cell to r/o C,E in the presence of Anti-D.  If that is your procedure, and your panel cells r'r and r"r were both negative (usually cell #5 and #6 ORTHO), then you should be fine. 

 

That said, the crossmatches should be repeated through AHG.  Maybe time for some competency refreshers?

[Irradiating Units in House]

The X-ray irradiators (one manufacturer is Best Theratronics of Canada) don't require the same level of security as the gamma irradiators.  They are not an active " radioactive source" that could be stolen, like the gamma sources are.  Security requirements on gamma irradiators are very extensive. 

 

Both are very expensive (>$200,000) and the x-ray irradiators have a very expensive maintenance contract also.  Both are easy to run and easy to train on.  Both are very heavy and require proper floor support (if you are not on ground level).  The x-ray irradiator from Best Theratronics requires a good, cool water supply for cooling also.  There may be another x-ray unit out there by now that doesn't need the water cooling, but I don't know the manufacturer. 

 

We have the Best Theratronics x-ray unit - Raycell - and irradiate approx 100+ units a month.  We are barely breaking even on the investment, so don't know if you could manage it with your current volumes.  No way to tell where the volumes are going on this either.  We have a new set of oncologists here who hardly irradiate anything for their patients.  They are following different guidelines, I guess.

 

In the US, if nothing else qualifies you for it already, the step of irradiating your own units makes you a manufacturer and the FDA will start to visit.  That makes for it's own set of headaches. 

 

I would recommend a lot of research first - and a good look at what your blood distributor does - they should have good, current information on the topic.  Good luck - it is a complex choice.

The FDA point alone would put an end to my speculation. 

 

I worked in a lab where we irradiated our own products.  We did a higher volume than you.  We already qualified as a manufacturer under FDA because we washed products.  It was worth it for us. 

[Gel vs Capture technology]

We use the ECHO with Gel/tube as a backup.  The ECHO (Capture SPRCA) tends to give more "warm auto"/non-specific reactions that are completely negative in gel/tube.  We don't use the manual capture station. 

[Donor Units Issued In Plastic Bags - Regulatory Requirement?]

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 

 

I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

 Well, let me tell you, I have!  I don't know what it is with me but just about everytime I drop one it bursts into a  red, yucky pile.  The bags we get from our donor center seem to have weak corners or something.  If you drop it just right, it will explode.  I seem to have perfected the "just right"

[How many rule-out cells does your lab require for antibody ID?]

When I first look at my antibody screen and ID panel, the first thing I do is go to my negative reactions and cross off cells that are single dose "homozygous" for the antigen group.  Next, I look at the double-dose "heterozygous" cells and, if I have 3 or more, I will cross those out as possiblities.  Normally, I have a clear cut answer at this point, which is then evaluated to make sure I have 3 positive cells that reacted and 3 negative that did not.  If there is more than one possibility, I do "rule-out" panels to either prove the existence of the addtional antibody or rule it out.  I believe Mabel Adams had an excellent power-point that perfectly illustrated this approach.  It has been very helpful.  Of course, there are often "stray" reactions or cells you would expect to react that don't.  You just have to use technical skills and techniques to investigate these reaction to a conclusion that your pathologist will accept.

[Anti-D in eluate of D+ person]

EGA is Ethylene/Glycine Acid and is used instead of Chloroquine treatment.

[Accepting RH type results on OB patients from other facilities]

We accept results from our sister facilites as our databases are linked. However, those results serve as our "retype". We still must perform our own testing. Antibody/antigen testing is also trusted from our sister facilities as well as our reference labs. As long as you are using outside results as a confirmation of your testing, you should be good. I don't know of any facility that would treat based on results not performed in their own laboratory, at least from a blood bank perspective.

[Sorvall Cell Washer Plus]

I too was under the impression that plastic tubes were not approved for use in blood bank.