Dr. Pepper

We use the Immucor screening cells. You can get them in a Cw+ version. Our current lot has homozygous doses for all Rh, Duffy, Kidd and MNSs antigens. Once in a while you might not get a S homozygous cell, but they're pretty good about the others. Last year we had our first reaction since we started IS crossmatches due to a "missed" antibody (anti-Wra), so I wonder if antibodies to low-incidence antigens not found on the screening cells could be more of a problem than missing weak antibodies due to heterozygous doses of antigens on the cells or using LISS vs. gel, etc. And let's see you find screening cells that are homozygous for K. By the way, I believe that Boral and Henry used a 2 donor pooled screening cell, pretty insensitive by today's standards.

This was not a scary quote but perhaps a scarier action: We just received a specimen from an outreach site for a culture and other tests. It was in a syringe with the needle still attached. The needle had no cap, but was "sealed" with a gauze pad and tape! That'll keep that sharp from sticking someone!

Did a Google search investigating automation options and came up with BBT. Glad it happened.

Back when we were delivering babies here, we tested all and ended up working up an awful lot of DAT+ A/B babies born to O moms. The problem is most had subclinical cases of HDN and needed no treatment. We switched to the AABB guidelines and only tested if the Moms were Rh neg or had antibodies. Had no problems, got no flack.

You may not manufacture anything, but you still have to report incidents where inappropriate blood is issued. We asked and were told to report an incident where a patient had a reaction to a unit due to anti-Wr(a). The screen was negative, IS crossmatch fine, but we happened to unfortunately give out a Wr(a+) unit. We didn't do anything "wrong" according to P&P, but they wanted it reported. It's easy to do on line, as is contacting them to see if an incident should be reported or not.

An eluate prepared from the baby's cells should show anti-D, a very good inference that the corresponding antigen is on the cells.

I concur with Malcom regarding the incidence of misidentifications- we only see the tip of an unknown iceberg. We can detect some in the lab by historical ABO discrepancies or delta failures in heme and chemistry, and sometimes nursing may realize they've got results on a patient who had no tests drawn, but the rest, the ones that don't not make sense (excuse the double negative) remain undetected and unquantifiable.

If the application of the second label is to get a LIS-type label with bar code, specimen # etc onto the tube, is there a way to generate these on the floors so they may be used instead of the registration label? Any relabeling or aliqotting generates another step in the process where mislabeling errors can occur, and you could avoid this step. I like the Bill's idea of adding a "Label checked?" test to your type/screen battery. We have a "Blood type verified" test in ours to document whether a second typing is on record for the patient, and don't give out non-group O RBC unless the typing has been verified. This might have prevented your ABO-incompatible unit from being issued. Our preop type and screen battery also has informational tests for pregnant/transfused in the past 3 months and date of surgery, which we find very useful.

We don't routinely retest. That's not a bad idea if you want to ensure that your test, automated or manual, was performed correctly, but the end result for a significant antibody is still the same, detectable or not: screen donor units and give antigen-negative blood. The warning bells in your computer system should go off otherwise.

Hi Johnny - Keep in mind that you are never totally confirming an ID with the 3+/3- cells, but rather reaching a 95% confidence level that your interpretation is correct (I always wondered who died and left Mr. Fisher in charge with his 1 in 20 standard...). This may not always be possible due to inherent shortcomings in panel antigen composition; the current AABB tech manual (p. 473) discusses alternative probability models. A very good rule of thumb, born out by the probability math, is to never to base your ID on the reactions with a single cell - find a few more e-, Cw+ etc. cells to confirm the ID. This will also allow elimination of more antibody possibilities when dealing with antibodies to high-incidence antigens. We buy 3 different panel lots a month, both for test volume and antigenic diversity.

We had Mysis for years and the previous comments pretty much sum it up. Every system will have its respective strong and weak points. As for the downtime files, it is a rather cumbersome system. We made the best of it by having the reports download automatically into a Notepad file. We currently have Meditech. Lab general is better than the BB package. Meditech's training and support were and are pretty pathetic. Our trainer told us proudly that he never had to take a biology, chemistry or physics course in college. They hire computer geeks and semi-teach them how to use the system but the kids are clueless about lab medicine. That, on the other hand, is the strength of Mysis. Their support is great because they hired a bunch of seasoned med techs who wanted a change of pace. They know their system, but more impoprtantly they know lab medicine and what you need to do your job well and easily. And Tucson is a cool place to visit for training.

I concur with the consensus that no one method will detect everything every time better than all the others. If it makes you feel any better, Issitt points out that if you have to go to heroic measures to detect an antibody, it will probably will not do too much (immediately) to transfused antigen-positive cells. And what about the patients with an antibody to a low-incidence antigen such as Wr(a), Kp(a) etc. not present on the screening cells and hence undetected, who have the misfortune of receiving an electronic or I.S. compatible unit that in fact carries the antigen. These are infrequent but unavoidable risks of current transfusion practices. That said, I still want to see my anti-Ks, too!

Bxcall1, AABB standards limits the 2 typing rule to computer XMs as an extra layer of safety since you woudn't have an incompatible wet I.S. crossmatch to fall back on. The typing result is, in effect, your crossmatch. On p. 451 of the new tech manual they do discuss the standard of comparison with past records and point out that one typing would not detect "wrong blood in tube" (WBIT) and suggest that the second typing may be helpful in detecting WBITs. But that's as far as AABB goes. The CAP is firmer on this issue mandating a plan to reduce the risk of mistransfusion and listing the second typing as their first option. I sleep better at night since we've gone that route.

We do it like Terri from Poughkeepsie, using another lab spec from a different draw, and rarely have to redraw patients, particularly inpatients. We have not had a significant increase in use of group O RBC for the "one time only" typing patients. And it seems all the same to me if you have two typings to look at from two recent draws, or you use your own past records, or those from a regional database, or from a previous LIS whose database has been converted into your current system, so long as your identifiers (name, DOB and unique ID# such as med rec# or SS#) match. We have also seen blood types change due to insurance fraud (once in a blue moon with our prenatal patients), but this will create a discrepancy that you evaluate. In any case, for ABO catastrophe to strike, you would have to have two back to back quite unlikely events (wrong patient drawn, lab mixup or mistyping, deliberate fraud). As has been pointed out, there is no substitute for just doing it right from the beginning: maintaining the chain of ID from collection to testing to transfusion.

Thank you LC, DJ and Linda for your input. A few years ago, we looked at our perioperative blood salvage use for 12 months. (The service was purchased.) # cases Cell-Saver used #equiv RBC units reinfused total units 41 0 0 5 <1 <5 18 1 18 4 2 8 3 3 9 1 5 5 1 6 6 1 7 7 1 10 10 TOTALS 71 68 So, if you use 2 units or greater as your financial equivalency point to allogenic blood, 64 of 71 cases were a waste of money. $52,416 cost for the purchased service $31,801 cost for a cell saver of our own and supplies for 75 cases $12,274 cost for 68 allogeneic units It just doesn't seem that we have the case mix to make this practical. I don't have the staff to spare a tech to be on hand for the procedures, scheduled or otherwise. Having the OR own the program, BB oversight or not, is a little frightening. And is allogeneic blood really that bad a product? In terms of infectious risk, the blood supply is safer than it's ever been. Our blood supplier has furnished leukoreduced components for years. Most of the blood we transfusde is 1-2 weeks old. The hospital is scraping for every penny. This just doesn't make financial sense to me. Dr. P

We have a neurosurgeon who has been lobbying actively for the hospital to buy a cell saver. Right now the OR subcontracts out for intraoperative salvage (an even bigger waste of money). We don't feel, though, that we do the types of bloody surgeries that would make this a good investment. Those of you who use them, how do you do your utilization review? Do you use 1000 ml whole blood salvaged as a break-even cutoff? Any input on the subject and potential pitfalls would be very welcome.

The kids these days don't know what they're missing. I started in the early 70s, and we also ate, drank and smoked in the lab. Do you remember hematologists tapping the ends of Sahli pipettes on their fingers to bring the blood level to the calibrated line, then wiping the blood off their fingertip? Or common mouth pipets - one tech would use it, put it back in the reagent container, then a second would use it....hey, it was a pain washing them! Three of the techs in our lab caught hep B, one died.

I am assuming in your workup you did some full crossmatches to detect an antibody to an antigen not found on the screening cells and undetected by an immediate spin or electronic crossmatch. (We had a reaction due to anti-Wra last month that fell through this serological crack.) I agree that eluates are still a good idea; the technique can actually concentrate an antibody, particularly if tested with PEG or enzyme-treated cells. I have read about some antibodies causing reactions that were only detectable using Polybrene.

John, if you never have seen a mislabeled lab spec in any dept God bless you and your institution! Hand-held devices reduce the risk of misidentification but do not eliminate it. We have had the 2-typing rule in place for several years and it's worked out well. We use any lab spec from a different draw to verify a "first-time typing' only, not for any pretransfusion testing. OR cases have the highest 1st time rate, about 50%. We don't bother retyping type and screen cases as they're not likely to take blood anyway. We do retype the cases where we've actually crossmatched their real non-O blood type. There's a dedicated phleb in the OR. The day before surgery we send up a list of patients needing redraw for a second typing or repeat type and screen because they've been pregnant/transfused recently and their PAT spec was too old. They get drawn as they get to the pre-op holding area. No one seems to mind.

We had a vascular surgeon at my hospital (before my time, circa 1960?) who insisted on a direct transfusion from his son. At least he let the BB type them both first. He survived the transfusion but developed anti-K.

Add me to the list as well. My daughter, 18 at the time, dropped from a 14 hgb to a 7 in a day and needed emergency surgery, but that was a week post-op when the scabs fall off. (Ironically, she's in her fourth year of med school now and applying for ENT residencies.) They don't go bad during surgery. If they do, your emergency release of group O policy should cover it.

There was a "House" episode a while ago where House ended up solving the patient's mystery illness by figuring out that he was having hemolytic reactions because they were giving him blood of the same (incorrect) ABO group that the patient said he was, apparently avoiding the annoying inconvenience of pretransfusion testing. The same episode featured a visit to the blood bank which in lieu of apparatus had a bunch of beakers and flasks filled with pale pink, blue and green fluids. My wife told me to stop jumping up and down and screaming at the TV, and just shut up and drink a glass of wine.

You might consider doing PEG autoadsorptions as outlined in the procedures section of the AABB tech manual. It's a lot cheaper and faster than WARM. There's a caution in the procedure about a potential dilutional effect. We tried the procedure on several spiked samples and saw equal or greater reactivity (titer) in the post-adsorption samples than the pre, using 6 drops of PEG/serum mixture. We like it a lot.