Sandy L

No, and to be honest, and at the risk of being accused of being big-headed, I am not too bad in the kitchen.  For example, when making a lasagne, I do everything from scratch, including making my own pasta and bechamel sauce.

Of course, since almost everyone has a computerized system of some sort, all "issuing" is done "electronically",
but I'mnotgoingtobotherwiththeIScrossmatchrightnowthankyou really is too  much of a mouthful for what we are actually doing, even though it is linguistically correct.  (Linguistic, from the Latin for "pretentiously verbal".)
OK, now I am really going back to work...
Scott

As a reference lab, if we identify anti-D in a prenatal sample and don't have patient history of RhIg administration, we try to get it from the hospital/Doc's office.  We also test a 1:4 dilution (no enhancement) at AGT.  If it's negative (which most of them are), our report includes a statement, "Due to the recent administration of RhIG, the antibody may have been passively acquired.  To establish this as the sole cause of the antibody's presence, repeat testing six months post-delivery should demonstrate a negative antibody screen."

Ann I don't think I ever really understood the Lewis system but don't tell Malcolm, he'll try to educate me and it's way to late for that.  

And in the examples you suggested - probably with the strategic application of some chemical and/or exotic enzyme treatments. Totally out of control. Scandalous!

I think that a lot of this "fixing problems that don't exist" stems from the change with CMS/CLIA when they combined all the subsections.  Immunohematology used to be separate, but now we are lumped in with Chemistry and Heme, and CMS can't quite get that blood bank is different.  Just my opinion.

I really only responded so that I could smash more light bulbs.........

Oh Web Master,
Thank you, thank you!

Oh Web Master,
Thank you, thank you!

Anti-ce is a so-called compound antibody (and is also known as anti-f).  It is an antibody that will only react with red cells that are derived from an individual who has the RHCE:ce gene, or, to put it more simply, it is an antibody that will only react with red cells that express both the c and the e antigens derived from the same haplotype (i.e. in the cis position), rather than derived from different haplotypes (i.e. in the trans position).  So, for example, the anti-ce will react with red cells that are DCE/dce (Rzr), but will not react with red cells that are DCe/DcE (R1R2).  It is actually usually made by an individual with the R1R2 phenotype (or probable genotype).  It is of fairly doubtful clinical significance (BUT, NEVER trust an Rh antibody).
Anti-hrS, usually seen in individuals of Black ethnicity (who have an e variant, but who have been exposed to a "normal e antigen through pregnancy or transfusion - or both!), mimics an anti-ce.

Oh Web Master,
Thank you, thank you!

We go to type specific as soon as we have some thawed. That means we might continue with the A plasma for a short time after we know the type because the type specific isn't thawed yet.  We don't use A plasma as universal donor for kids under about 40 lbs.  We don't have a specific limit for bigger patients.  If we don't have a blood type yet, we are giving O red cells.  By the time we have given more than 4 A plasma units the patient is about half full of O red cells so the anti-B in the plasma has fewer targets. 

We would not routinely perform eluates if the IgG DAT was negative but if we suspecting a delayed hemolytic transfusion reaction we would definitely consider doing this testing.  I have been able to elute IgG antibodies from DAT negative samples on several occasions.  Initially I thought this phenomenon was unique to the eluting of anti-A or –B from cord samples.  I think we’ve all experienced this, with mom group O and negative antibody screen, infant group A or B and negative DAT.  MD suspects ABO HDN and requests elution.  Generally you will be able to elute the maternal IgG ABO antibody despite the negative DAT.  As a med tech student we were always taught that this related to the way the infant’s ABO antigen developed, less branched structures.  Over the years we have seen that this happens with other antibodies too.  In several cases where mom had a known significant antibody, and infant DAT was negative but infant was positive for the antigen to which the antibody was directed.  This has happened with anti-c, anti-Jka and most recently with anti-Ge3. Most of these eluates reacted 2+ to 3+ despite the negative DAT.  Also think about Delayed Transfusion Reaction Investigations that you may have performed where the DAT may be weakly positive but the antibody in the eluate reacting quite strongly.  Another observation: Just recently I was preparing competency unknown samples for eluate testing by coating cells with various patient antibodies.  Some of the samples had DAT’s that were negative or only weakly positive yet the antibody was recovered in the eluates, again reacting 2+ to 4+.  And this was not even increasing the concentration of red cells as Malcolm suggested.  If you think about it, the process of preparing the eluate really does have a “concentrating” effect.  The eluate is prepared from a large mass of red cells where the packed red cell volume to eluate volume is nearly equal.  That eluate is then tested against a very diluted concentration of reagent red cells, e.g. 3-4%, compared to the very MUCH larger quantity of cells that it came from, thus you are greatly increasing the sensitivity of the test.

You might find this article form John Judd to be of interest:
Judd, W.J., et al, The Evaluation of a Positive Direct Antiglobulin Test in Pretransfusion Testing, Transfusion 1980; 20:17-23
 
In this University of Michigan study, an analysis was performed of 879 samples with positive direct antiglobulin tests.  Eluates were performed and 83 were reactive.  Most were autoantibodies and a few contained penicillin/Keflin antibodies and a few contained passively acquired anti-A. 
In only 11 of the 879 cases allo-antibodies were detected in the eluate.  After 14 days allo-antibodies detected in the eluate were also detected in the plasma in all but one patient sample that eluted anti-K 17 days post transfusion. 
 
The article states, "One of the six patients whose red blood cells eluted a transfusion-induced alloantibody, but in whom the eluted antibody was not detected in the serum by routine pretransfusion screening tests, had been transfused 17 days before a detailed serological evaluation of the DAT was performed (case 4, Table 3). The red blood cells from this patient eluted anti-Kell. This isolated instance does not warrant an extension of our definition of “recently transfused” to a post transfusion interval beyond 14 days, for to do so would only increase the number of samples requiring evaluation with very little corresponding gain in terms of significant serological findings." 
 
The University of Michigan established a 14-day cut-off for "recently transfused" when determining if an eluate needs to be performed.  We have chosen 28 days as our "recent transfusion" cutoff to perform an eluate.  If the DAT becomes positive within 28 days we will perform eluate, if greater than 28 days since transfusion we will not perform eluate.  The article was written in 1980 and the automated testing methods for antibody detection widely in use today are likely to be more sensitive than those used in the study.

You might find this article form John Judd to be of interest:
Judd, W.J., et al, The Evaluation of a Positive Direct Antiglobulin Test in Pretransfusion Testing, Transfusion 1980; 20:17-23
 
In this University of Michigan study, an analysis was performed of 879 samples with positive direct antiglobulin tests.  Eluates were performed and 83 were reactive.  Most were autoantibodies and a few contained penicillin/Keflin antibodies and a few contained passively acquired anti-A. 
In only 11 of the 879 cases allo-antibodies were detected in the eluate.  After 14 days allo-antibodies detected in the eluate were also detected in the plasma in all but one patient sample that eluted anti-K 17 days post transfusion. 
 
The article states, "One of the six patients whose red blood cells eluted a transfusion-induced alloantibody, but in whom the eluted antibody was not detected in the serum by routine pretransfusion screening tests, had been transfused 17 days before a detailed serological evaluation of the DAT was performed (case 4, Table 3). The red blood cells from this patient eluted anti-Kell. This isolated instance does not warrant an extension of our definition of “recently transfused” to a post transfusion interval beyond 14 days, for to do so would only increase the number of samples requiring evaluation with very little corresponding gain in terms of significant serological findings." 
 
The University of Michigan established a 14-day cut-off for "recently transfused" when determining if an eluate needs to be performed.  We have chosen 28 days as our "recent transfusion" cutoff to perform an eluate.  If the DAT becomes positive within 28 days we will perform eluate, if greater than 28 days since transfusion we will not perform eluate.  The article was written in 1980 and the automated testing methods for antibody detection widely in use today are likely to be more sensitive than those used in the study.

Ours are transported this way as well, however we have still had rare instances where they were not within the 20-24 degree range when they arrived during extreme weather conditions.  When this happens we call the supplier and they decide if they are acceptable or will be replaced.
I believe that the original question was for units issued for transfusion but returned unused.  For this scenario we take the temps, examine the product, and decide from there.  

It would certainly nice to find out about mom making a new antibody after delivery for transfusions or her next baby.  Like with most OBs whom we have no reason to test in the days after delivery, we would expect to detect any new antibodies on the prenatal testing for the next pregnancy.  If we needed to transfuse her, we would expect to find them on the crossmatch sample.  I recognize that the titer could drop below detectable level by the time testing is done for a later baby.  If we are worried about that, we should do screens on all post-partum moms.  Also, the odds that she would show a new primary response antibody within a couple of days of delivery are small enough that I wouldn't feel too worried about it.  If we wanted to detect new antibodies, about 2 weeks post-partum might be optimum, but that is not current standard of care anywhere that I know of.

A few comments:  first, I really like what was said above about this being a pubic forum.  You don't want your employees seeing comments like that.  Second:  if you are in charge then YOU are in charge.  Set the ground rules and enforce them.  You will need your Medical Director to back you up.  Blood Bankers are notorious for not letting go, esp the older ones (like me).  If you feel your techs are not able to perform up to their performance programs document, retrain, document - once they see you documenting things they will get the hint.  Don't let them boss you around.  Ask them what the procedure says.  That's why there are manuals.  If you think they are busting your chops, keep a record and then you can "retrain" as indicated but you also have a record for competencies at evaluation time - but you must make the effort to provide retraining.  If they balk, document . . . It's a fine line to walk.  When you have more management experience you will understand.  In many instances we were promoted to management because we were good serologists . . . suddenly we had to learn to handle people - a whole different ball game.
To the person that started this post:  getting calls at all hours is part of being in charge of the BB.  On the off shifts, I have found that a bit of extra time for training goes a long way in reducing the calls.  No matter how simple the procedure seems to you, esp if you are dealing with generalists, and it is something that occurs infrequently.  Don't make it so they don't call when they really should.  If you have a dedicated BB staff it might be a different story.

I'm jealous.  You two know all the rock stars.  

I'm on call 24/7.  I tell them to consult the policy first.  If you try and can't find it anywhere in a policy, ask your coworkers to show you where to find the answer.  If nobody else on your shift can point you to it, THEN you call me.  Do not guess!
I get a lot more text messages than I do phone calls.  Usually they already know the answer, they are just wanting me to confirm their answer.  We have quite a few generalists on my eve and night shifts that are not very experienced with difficult BB issues, so I have no problem with them calling me.  I would much rather that than a patient gets hurt.  I feel like it's part of my job as BB Manager to support them and have them feel confident in asking for help when they need it.
I think the key to "weaning" them from calling too much is giving them really great policies (written very simply so anyone can follow them, even if they have not done the test for a while) and some good flowsheets (which I am still working on) for antibody workups, RhIg workups, etc.

I'm with Terri. With those things in place and as they learn and grow, the calls get fewer. (Until you get a new employee and you start over.) If the call was something someone should have know, I ask them the next day if they've looked at procedure #(whatever is appropriate), ask them to read it and coach as needed, as often as needed. They get the idea pretty quickly - if I don't bother to look it up now, I'll have to look it up later anyway. There have been occasions where I needed to make a change to the policy to make it better-that's a good thing. Students and trainees are the best for calling those things to my attention. Sometimes they are just stressed out and they can't pull what they need out of their brains under pressure. Bottom line, better to get it right up front than fix a mess later.

I'd say the fact that you are getting so many calls means that either training/competencies aren't up to scratch, or the SOP is lacking. You say that the tech had signed to say they were competent in the task - who had verified this? It sounds like you need to look at your own management, rather than blaming the techs.
I've been in the situation you are in as a young supervisor with people who are older (and more experienced in terms of years) below me and it is a hard place to be. Ironing out the issues with poor performers is the hardest thing to do and the only way to do it is with good competency-based assessments. Another thing to consider is including a list of changes when putting a new SOP out - you will find that 'old-timers' think they know the SOP so won't bother to read it (I've been guilty of that myself). Another thing I did was introduced an hour a day for each section where one person (on rotation) could spend the quietest time of the day (usually 11-12 or 2-3) getting up to date with any outstanding training. It meant that everyone (in theory) got an hour a fortnight. 
Do keep in mind that how they perform, and your response to it, will reflect directly on you - it's a good idea to keep them on side and make sure competencies are absolutely spot on. Anything that isn't can be brought up at their appraisal as a goal for the next year (not a stick to beat them with). Help your staff, keep them happy, and they will start having the confidence to trouble shoot themselves without fear of reprisals or looking stupid.
You could really make something positive out of this situation and get brownie points for it in your own appraisal.

Hi
Well let me deal with the 'ergo' part first.  Depending ion the circumstances, enzyme-IATs are ALSO done on gel.  If you have the slightest doubt about Kidd antibodies, this is one of the best methods for finding them.  It is just not very common (but not unknown) for this to be used as a routine method for ALL antibody screens
So why is gel more sensitive than tube.  First of all this ONLY applies to atypical antibodies.  the reason lies in the method.  Firstly, the tube technique tends to be (in most people's hands) very imprecise, with most people using drops (1 or 2 or 4.....) of plasma and drops (1 or 2...) of cells (3 or 4 or 5%.....) with or without LISS; if with LISS then either with LISS addition or by suspension of the cells in LISS; incubating for x minutes where x can be from 5 to 60 mins.  Then the tubes are washed 3 or 4 times with a spin cycle that is xxx(?) rpm for yy minutes - you can fill in your own values, removing some/most/all of the liquid between washes.-  Then to your possibly quite diluted remaining red cells, from which you may have washed off weakly attached antibodies anyway,  you add 1 or 2 drops of AHG and spin with a spin cycle that is xxx(?) rpm for yy minutes then read by eye/with a magnifying glass/with a microscope after re-suspending the cell button from so gently that you can't see anything to so hard that all your weak agglutinates have been shaken away................I will admit the variation in any one site is much less than this, but globally there is just no standardisation.  Gel is standardised, can be done on an instrument, and there is no washing.
But there are still good reasons for gel users to revert to tube techniques from time to time. 
Does that answer your question?
(And yes, I've done literally millions of tube IATs in my time; and no, I would not go back to using them as a routine method EVER!)

That works, they've been pretty helpful (I've had to ask for new E codes).
ICCBBA released a new tool this summer where you can choose some product specifics and attributes and it provides a list of likely codes. Only saw it yesterday but it seems like it'll be helpful.
 

Back in 1994 we moved from cards to a computer BB system and discontinued even touching those dang things again.
I agree with Malcom, something from 1970, gee that could change dramatically and especially if you can't positively identify these patients I wouldn't worry about these pts or their associated antibodies.
When you say "The antibody cards were updated to the computer during the last software update, but I am reviewing them all again anyway just to double check." you have done your validation and due diligence.  Maybe create a document that shows you have done this validation and it's all in the computer now.
Away with the cards!!  Get some marshmallows, graham crackers and chocolate bars, grab a fire extinguisher and head for the parking lot.  Smores for everyone.  Just kidding :-)