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Posts posted by Dr. Pepper
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In the US, we use metrics in the lab - Celsius, grams, milliliters, centimeters, etc. The 'outside world' uses Fahrenheit, pounds, cups, feet, etc. ... even nurses and MDs! It would be nice to go metric 'out there', too!
There have been sporadic attempts to try to introduce more of the metric system into US culture but with very limited success. Once in a great while you'll see road signs that say "Boston 50 miles/80 kilometers", and most rulers have an inch scale on one side and a neglected centimeter scale on the other, but that's about it. Body temperature is 98.6o outside of the lab, kitchen fridges run at 39o. Interesting that hospital labs are about the only metric stronghold.
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Type and screen on current admission for all the above reasons.
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We do this similarly. We have one "test" (lab eyes only) in the typing battery "PREVIOUS RESULTS CHECKED?" with only one response "Previous results checked", since you have to do it with every specimen. We have a second test "ABO VERIFICATION" with 4 responses:Our ABO/Rh test has a result detail "History Check" that has 3 possible responses: Previous ABO in HX, No ABO in HX, or Retype required. All of these responses display in the patient's Medical Record. For patients with no history we use the "No ABO in HX" for non-compatibility ABO/Rh requests and we use the "Retype required" if the ABO/Rh is for compatibility testing. Retype required will automatically reflex an order for the patient to be drawn for the 2nd sample.
ABO GROUP VERIFIED
1ST TYPE, USE O RBC
ABO VER BY AUTOL DON (if we have an autologous donation)
USE ONLY FOR ABO VER (for CBCs etc. that we have snagged just to do the 2nd type)
We also have a bright little sticker for the 1st time typings to help flag them.
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Such is the price for a life of dissolution and debauchery - but it HAS been fun.
- AMcCord and Malcolm Needs
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One would also think that the reference lab would have the reagents necessary to remove the IgG if need be.
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How timely. One of our old IEC Centra Ws is getting its innards replaced and the other vaporized my panel tubes yesterday afternoon along with a couple of the tube holders in the centrifuge head and cracked the bowl on the lid. Cleaning up 10,000 pieces of glass the size of pinheads glued to the inside of the beast what not what I wanted to do at that moment. I went to Clinical Engineering and retrieved the other head/tube holder but my supervisor told me I could order a new one. So thanks for the reviews.
Phil
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Thankfully my physician daughter seems to have been absent the day in med school when they give the workshop on arrogance and intractability.We can change any result in our LIS, but it keeps track of it, shows who did it and on what date, and throws an exception. We would always have a comment attached why the change had to happen. But nothing can ever really be "deleted".
While we're on a physician complaint kick...a surgeon called last Saturday SCREAMING that we did not have a certain size of tissue in Blood Bank that he needed for a Sunday surgery. He said he is filing an incident report and slammed the phone down. I wish he had a chance for us to tell him:
1. He used the last one the day before, Friday afternoon after 4 pm. Unless the Tissue Fairy comes overnight...
2. Hospitals are open on weekends, most companies are not.
3. This particular piece of tissue costs about $20,000, so we can't really keep multiples of every size in stock.
4. This is a new tissue, we've just had it for a couple months...how did you save lives before it was invented?
OK, rant over. For now.
- Malcolm Needs, Sandy L, AMcCord and 1 other
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Like Mabel for the same reasons. We also will give AB FFP and, if possible, AB platelets until we get the 2nd type. That may be a bit of overkill (no pun intended) but it doesn't happen very often at all - most of our recipients are frequent fliers or have other specimens around that we can type.
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In what world do surgeons/anesthesia review charts prior to the surgery?
Goodchild, you hardened cynic - why that would be the one long, long ago, in a galaxy far, far away, where they don't thumb through the chart while the patient is getting prepped and say "Holy bleep! His INR's 7, his platelets are 6, his hemoglobin's 5, his glucose is 4........."
Hey, I said that was the point, not that anyone did anything about it. But I LOLed too.
- Malcolm Needs and AMcCord
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Another issue with shortening the preop window is that, although we do sometimes have departmental tunnel vision, there are other lab tests to be performed and acted upon besides pretransfusion testing. The whole point of getting the blood work done many days ahead of time is to get the abnormal glucose, creatinine, H&H, coag etc. sorted out before the day of surgery - not just antibody problems. So there would be less time to deal with these potential problems as well.
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In 30 years had exactly one case of mislabeling from our local blood supplier. It was an autologous unit and they used to write in the ABO/Rh by hand. Someone put A Neg on instead of A Pos. Shortly after they switched to computer-generated labels.
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"I told him that such an action violates every regulatory, legal, ethical and moral standard I can think of, especially since the original results cannot be proven to have been wrong and it sounds like it was an attempt to avoid admitting a mistake either in collection, labeling or testing."
AGREE, AGREE, AGREE! And with Goodchild. From time to time we encounter historical typing discrepancies like this. We determine the actual type, as Goodchild, with two samples. Then we see if there's a technical reason (weak D, BMT, change of reagent/methodology - we use tube and our affiliate uses gel). Then try to figure out what happened, sometimes impossible because it always seems that the old result from 6 months ago was the bogus one. Besides Goodchild's scenario it could have been WBIT, identity borrowing or theft, or a mixup in samples in the lab (I've seen all of these). Document, correct old reports, incident report, and correction in the LIS BB history (when you're very sure of the true ABO/Rh).
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Makes sense Mabel, and could explain the jump in reactivity from 1+w (IS) to 3+ (IAT), although that seems to be a pretty big jump. I had been considering a bit of D+ RBC from a different patient in the RBC suspension but I think txlalabguy82 only does one patient at a time.
And txlalabguy, please don't hate blood bank! I think you need to compartmentalize all the issues running around in there (I do know that can be hard) and just concentrate on the job at hand. Blood bank, chemistry, UA, heme, it's no different - keep focused on what you're immediately doing, and let the other guys out of the boxes when it's time for them.
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We tried these years ago with limited success - our own patients wouldn't show them to nursing/MDs. A few years ago I did get a call from a patient in her late 80s who had received her card in the 1970s, and, 40 years later, presented it when she went to a neighboring hospital, who never gave it back! We got her a new card and wished her well. Her antibody, by the way, was no longer detectable, so I guess our old program was not a total failure.We had one once that was sent in to us because it was getting a bit battered and bruised, and the lady wanted a new one. The original was signed by a certain Dr Ruth Sanger!!!!!!!!!!!!!!!!!!!
Anna is correct about the patient education piece. And I liked the letter a lot, but I question whether the patient's doctor is the best person to give the info to. Our cards (we are trying this again) read "Should you require transfusions in the future, it is important to forward this information to the blood bank at your hospital."
You can get card stock and a template from Avery (#5871) and make the cards from any printer.
- AMcCord, jayinsat, Malcolm Needs and 1 other
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I agree with Maureen about the potential feedback. The more lead time you have to sort out any problems, the better.
Welcome to the site by the way KMMinNH.
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Very interesting SMW about the polyclonal vs. monoclonal reagents, thank you.
As for the initial, non-repeatable results: I would certainly think that rapid in vivo clearance could make a difference in what you would see in the original specimen vs. one drawn, say, 6 hours later. But how are those baby cells going to get hemolyzed in vitro using an EDTA sample that does not have any active complement?
Second, the scenario mentioned above sounds reasonable with a minor population of cells getting trapped in the agglutinates. But in this case the problem is how did those baby cells, which were plentiful enough to give a weak 1+, vanish from the specimen tube. They would have been the minor population, but also the ones involved in the agglutinates (with a polyclonal anti-A), not the ones not involved in the agglutinates, the opposite it seems of the AABB's scenario. They seem to have vanished from the specimen tube prior to testing, not during testing with monoclonals.
Many years ago we had a unit returned from the floor. The story was that they had started to hang it on the wrong patient, but then realized the error and never actually infused any. But some volume seemed to be unaccounted for. Trying to see if there were indeed any of the cells in the patient was complicated by the fact that the patient had recently received several other units. The donor unit was O, the patient A2. We typed the patient and all the units for a bunch of antigens and found that the unit in question was S-, where all the other units and the patient were S+. How to separate just those cells? Our reference lab suggested differential sedimentation: mix a dilute suspension of patient cells with anti-A (polyclonal), let sit for 15 minutes or so, during which the agglutinates would (hopefully) tumble down and the O cells remain in suspension. Then harvest the top half of so of the suspension. We repeated this several times, and ended up with two wispy cell buttons that typed S- and H+ (4+). So we seemed to have demonstrated that the patient did get a bit of the blood in question. Could that have happened with the patient we've been talking about as the tube sat. I think not, I think a tube of whole blood or packed cells would be a whole lot harder for the agglutinates of baby cells to work their way down.
Please forgive me all if I appear contentious, we're all just trying to puzzle out a mystery.
- galvania and Malcolm Needs
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We had been using an arbitrary 14 days if not pregnant or transfused, but recently expanded to 21 days or the OR's request - too many redraws. I think the only limit is your own comfort zone and storage space for specimens for serologic crossmatches and/or keeping them for a week post-transfusion.
If you perform serologic crossmatches and transfer your serum/plasma to an aliquot tube while doing your T&S, I have noticed that once in a while there will be a turbid layer of microbial growth in the aliquot tube after several days' storage.
Our LIS electronic crossmatch requires an antibody screen within 72 hours but this can be overridden.
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I'm sorry, Anna, but I don't see why they wouldn't be evenly dispersed in the sample. How about mixing well and doing a K-B? If you look at a zillion cells you should be able to see if there are fetal cells there or not, a lot or a few.
Phil
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A few thoughts (always a dangerous thing when it happens to me):
- You could put Malcolm's theory to the test and try repeating the testing with reagents and, for that matter, the patient specimen, straight from the fridge.
- If Anna's theory about 2 cell populations is correct, why weren't the reactions repeatable when retested several hours later? The baby's cells should have still been there.
- Speaking of 2 cell populations, was another D+ patient being tested at the same time? Could some of his cells have gotten into the RBC suspension that was mostly D-? Years ago we had three patients in a row who had positive antibody screens. They all had anti-D. They were all D- but the auto controls were all positive. The tech had aliquotted the sera off of three clots sitting side by side into second tubes in the rack for the testing, then added her typing reagents to the testing tubes. Trouble was, she apparently added a drop of anti-D to each of the three serum aliquot tubes instead of the tubes for the anti-D testing! Point is, maybe here the wrong stuff got in the wrong tubes.
- The initial testing sure looks like a weak D though.
Who really killed the Kennedys? Sometimes we will never know the answers. I'll stop thinking for now.
- Yanxia, John C. Staley, AMcCord and 1 other
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I interpret the AABB standard to infer that you still need to test with reagent RBC for the presence of antibodies that cannot be excluded with negative reactions with your screen. I would not rely on the AHG crossmatch to pick up the anti-K, -Fya, -Jka etc that might hidden in back of that C-pos screening cell that reacts, particularly in the case of a newly appearing antibody that may be quite weak. I would much rather eliminate the antibody through standard techniques with antigens whose encoding genes are, if possible, in a homozygous dose (that verbiage was just in case Malcolm was listening).
- tbostock and Malcolm Needs
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For what it's worth I was told by an AABB assessor that there is not any experimental data that shows the blood turns poisonous after 4 hours, but that it it was just a "sounds reasonable" thing, that you should be able to get a unit into a patient in 4 hours and that there's an increasing chance of bad things happening to the blood as time drags on after that.
I would guess the CAP citation is the one about staff being knowlegable (i.e. following) about procedures. If your P&P says everyone should be wearing red clown noses, you'd better be doing it when they come.
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We also have a SOP SOP. We have a template but it's more structural in nature (header boxes to fill in with title, date etc). If you vary the font size or style it's OK (for now). I use a 12 on my P&P, probably because that's what I can see with my reading glasses! And this makes me realize I'm just as centric as those young bastards who write things with a 10 font that I think are too small.
I'm convinced we got a CAP specimen wrong once because an aging tech analyzed the wrong one because she couldn't read the apparent 2 font CAP uses on the vial and mixed up a 6 and 8.
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1. Both.
2. Mostly AP. Little BB, ? 1%
3. I am designee.
4. Licensed for 250, 150 actual.
5. 200.
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Ditto to all the excellent advice from DebbieL. I would bet your lab has a template with a standardized header, format etc. If not, you get to make one. If you are CAP inspected, make sure your procedure complies with the All Common checklist as well as the Transfusion Medicine. And check out the AABB Standards if you are AABB. A few other thoughts re the art of writing P&P:
1. These are directions for performing tasks. Make it easy for the staff to find what they need. For Debbie's procedure, in the Table of Contents under the procedure name, list A. Daily Checking of Continuous Monitored Chart System: with a page number, B. Weekly Chart Change – etc.
2. You can crossreference to other procedures. Too much of this, however, gets annoying, because you end up skipping all over the manual.
3. Staff needs to review and sign off.
4. Yearly competency is a good place to review P+P. Ask questions that they might not know the answer to off the top of their heads. Besides being a refresher for them, and an opportunity to address your pet peeves, it serves as a good critique for the P+P. If they can't find the answer readily you need to make it easier to do so.
Weak D
in Transfusion Services
Posted
Until the next day, when it's back to where you started.