Dr. Pepper

All may not be lost. One of our seminar speakers last week did a talk on FFP which included some data on stability of FFP stored for various times/temps out of range. I'll see if I can get the references from her.

I think our pneumatic tube might be a her. If it were a him, it would never ask for directions before it goes anywhere.

OK, the only magic to the "3+3" rule is that if you plug those numbers into the horribly unwieldy formula for Fisher's exact method of calculating probability, you will get a probability (p) of 1/20, or a 1 in 20 chance that the reactions could have occured by chance, or a 95% confidence level that your conclusion is correct. (This is a totally arbitrary number by the way.) Lower p values (1/15, 1/9 etc) allow for too much chance of random association. Higher values (1/28, 1/56) show that there's a much smaller chance that your conclusion is incorrect.
 
But there are other magic combinations that will give you an acceptable p: 5 and 2 (1/21), 4 and 3 (1/35), 6 and 2 (1/28) and so on. You do not necessarily need 3+3. See Goodchild's reference.
 
You run into problems when you only have one positive or negative cell: 7 and 1 (p of 1/8), 8 and 1 (1/9), etc. You would have to get to 19 and 1 to get the magic p of 1/20. If you think about it non-arithmatically, what if your one reactive panel cell is also positive for an unlisted low frequency antigen? What if your one negative didn't have serum added or isn't reacting for some other technical reason?
 
So you don't necessarily need 3 Cw+ cells; 5 or more neg and 2 pos would suffice. And you don't need 3 Js(b-) cells; 19 pos and 1 neg would be OK statistically. The problem I see with the high incidence antigens like this would be that with only one negative cell with which to rule out, you would still have a bunch of other antibody choices you would like to rule out, hence the need to test more negative cells.
 
So, pedantry aside, the bottom line is "don't base your ID just on the reaction with one cell". A second cell of similar makeup coupled with the pos or negs from the rest of the panel should bump your p past 1/20.

Labgirl, I'm gently disagreeing with you as well. Not everyone does autoadsorptions, and far fewer can do homologous adsorptions on the recently transfused or have the luxury of the time and $$ to send it out to a reference lab to perform. While, in some cases, it may be less sensitive than some techniques, saline testing will still do a good job of detecting most antibodies. There was no plague of acute hemolytic reactions during the decades when saline or albumin testing was the norm. No technique is the best in all cases, and the sensitivity of gel and solid phase can be a double-edged sword when autoantibodies and other insigificant findings pop up in the testing. What about the "garbage" reactions seen with these technologies, where techs report "Gel- (or solid phase-) reactive antibody of undetermined specificity" and give crossmatch-compatible, or repeat the screen with PEG and just report it as negative? There are many other scenarios where there may be a slight trade-off in sensitivity, such as the dilutional factor involved with using inhibitory substances (Lewis, P1, Sda, Ch/Rg, REST etc), but it's acceptable in terms of the outcome ("calling it good"). There are acceptable risks associated with any transfusion, such as those with immediate spin or computer crossmatches, where antibodies to low-incidence antigens not on the screening cells may be missed. The potential risk of "missing" an antibody that's teetering on the edge of detectability is outweighed by the advantage of getting rid of the interfering activity and getting your patient some blood.
We will sometimes use no enhancement media to avoid warm autos (and colds), using 3-4 drops serum, a 60 minute incubation, and mixing the tubes a few times during the incubation to let more cells bump into more IgG.
And it's not a bad idea to check it out yourself if you have doubts about any procedure. Our LISS reagent cautions about maintaining the proper 2/2/1 ratio of LISS/serum/cells, which made me nervous about some techs not carefully counting their drops. So I titered antibodies in non-reactive serum and tried the dilutions with 2/2/1, 4/4/1, 4/2/1 and 2/4/1 ratios and found no appreciable differences. I'm not advocating going against P&P but I felt better knowing the world wouldn't end if someone added an extra drop. You might feel better yourself about the saline technique.

Kaleigh, whenever we encountered a specimen showing nice rouleaux I would gather all the old lab specs on the patient, pool them and freeze aliquots to torment future generations of students. You could also have your buddies in Hematology be on the lookout for them as well.

Kaleigh, whenever we encountered a specimen showing nice rouleaux I would gather all the old lab specs on the patient, pool them and freeze aliquots to torment future generations of students. You could also have your buddies in Hematology be on the lookout for them as well.

Kaleigh, whenever we encountered a specimen showing nice rouleaux I would gather all the old lab specs on the patient, pool them and freeze aliquots to torment future generations of students. You could also have your buddies in Hematology be on the lookout for them as well.

amym1586, on 22 Jul 2014 - 5:19 PM, said:
Is there a way to make a fake Lui Freeze ?
I start off my students doing a mess of typings on random "just in case" tubes from the main lab about to be discarded - CBC and coag tubes. You don't need to do 40 typings to learn how but this also gives them good practice making suspensions, reading reactions, figuring out which end of the pipet to hold etc. Save the specimens. Next day, I tell them they will do one typing that will take all day. I show them on paper what they would have done to get to that point: O on front type, A or B on back type, couldn't get that "missing" back type cell to react with a cold back type. You should have plenty of O and A specimens, maybe a few B/AB. Make pools of each type and wash. To make your weak "patient sample", spike 2-3 ml of washed packed O cells with 10 drops of A or B cells. They also do the procedure on straight O and A (or cells. It works with either human source anti-A or -B (saved from the previous day's specs) as well as reagent monoclonals. I probably should spike the mock patient sample with fewer cells as you will probably adsorb out all the antibody, but they get the point and I want it to work.
 
Other student stuff:
 
A2 or A2B with anti-A1: spike a real A or AB serum with reagent anti-A1.
 
O with weak anti-A+B: make a 12-tube serial dilution of O serum. Test each dil against A and B cells in the cold. Find the dil that gives you a w+ or 1+ in the cold. Make sure that dilution is not reacting at IS. Make up more of that dilution and give them O cells and that for their typing - the goal will be to get them to do a cold back type.
 
Typing with unexpected abs in serum: Spike your serum with reagent anti-c etc or a patient ab that will react at IS. 
 
Review your panels often. If someone has an antibody, scrounge up the stored tubes, even coags, from other depts if they save them, then pool and freeze to torment future students down the line. Freeze some specs with nice rouleaux.
 
Make DAT positive cells for eluates by adding reagent anti-D to Rh+ cells as others have suggested. Our QC reagent ab has anti-A, -B, -D, -c. After the kit ODs I use it to get a "panagglutinin" by sensitizing D+c+ cell, or auto-anti-c by sensitizing D- cells.
 
Transfusion reactions: Add 1 drop check cells to 12 or more drops non-coated cells to give mixed-field agglutination.
 
I teach PeG autoadsorption by starting them with a pseudo-patient with the above "panagglutinin" on cells and in serum. They then use some frozen samples with anti-K and a couple of old CBC tubes that I've typed and are K- for their patient serum/plasma and cells (there's no "autoantibody" in the sample now but they'll never know that).
 
Take advantage of fresh real specs when you have them (known weak Ds or weak subgroups), and in particular freeze specs with cool stuff like and-Sda or RG/Ch that you can do urine or plasma neutralization with.
 
I also take them to watch a unit being hung, show them our QA process, involve them in audits and whatever periodic QC comes due while they're in the dept.

I'm SO glad we don't have one of these.
 
 
OK: chart/alarm shows temp stayed within range, temp was recorded once during the day. Keep the blood.
 
Not OK: chart/alarm shows temp stayed within range, temp was not recorded once during the day. Throw away the blood.
 
I kind of like Dave's point "Better to eat them and use the incident as a means for better compliance with regulations." However, I don't see a difference in how the blood was stored in the 2 scenarios, aside from a note on a logsheet, so I side with goodchild and kirkaw. The real issue, as Dave continued, is that the units could have been taken out of the fridge, sat and cooked for half a day on a counter, then put back in. In either scenario you wouldn't know it. 
 
There's my non-answer. Throw them away if you want to make a point to the OR, but I see no difference in safety whether someone recorded a random temp or not.

I concur with the second theory. And is any else besides me annoyed when physicians order "lyme titers", "giardia titers", "hepatitis titers" etc on any number of qualitative tests that we do? Aside from prenatal antibodies and ANAs, there aren't too many other things these days we actually titer. So I think that not many doctors know what a titer actually is, let alone interpret one.
I caught my daughter, a budding pediatrician, misusing the titer word, and corrected her. I asked her if she wanted to be just another dumba*s doctor who was the laughingstock of the laboratory. She have me a crude response. That ChristmasI gave her Blood Transfusion Therapy: A Physician's Handbook and the Circular of Information in her stocking.

Sorry for the delay but I've been retired for 2 years and have not been hitting this site much. We would order the blood on a new accession number that also had a nonreportable test SAMPLE USED to record/trace the original sample.

I think our pneumatic tube might be a her. If it were a him, it would never ask for directions before it goes anywhere.

We (ASCLS-CNE American Society of Clinical Laboratory Science of Central New England) put on a 3 day conference in Providence, RI, each spring. Like the Maine meeting, it covers all lab areas and we welcome all vendors and sponsored speakers.

Terri no doubt has an elegant solution involving packing foam, but have you called Helmer? Their tech support is very good. I'm not aware that the scribes can be adjusted but you never know...Short of that, you could replace the scribe, readjust it every morning (you're probably looking at it daily anyway), or learn to live with it. An hour is not much of a space on that little disc; I'm happy if my techs just get the right day of the week and AM or PM. The purpose, beyond satisfying AABB and CAP, is redundancy to your alarm system to see if your blood got cooked while no one was looking, and to see if an unfamiliar tracing might indicate a potential problem down the road. The batteries, by the way, are only for backup with a power loss and shouldn't have anything to do with normal operation.

Good to hear from all the other Meditech BBK package fans. It did indeed take a while to do the historical conversion. Sunquest hired seasoned blood bankers to make, modify, instruct on and implement their LIS module. They knew exactly what their customers' needs and concerns were. Meditech primarily hires computer geeks straight out of college who learn the system by playing with it and guess what their customers need. Our initial Meditech instructor told us he never had a chemistry or biology course in college. Another used anti-A as an example of an unexpected antibody. I guess you get what you pay for.........

Why, off the top of my pedantic head! Actually, it just took a few seconds to look it up on Wikipedia and cut and paste. I just thought it would be fun be be a pedant discussing pedantry. Kind of made me feel like an autoantibody.

I understand completely. The word pedant, by the way, is thought to derive from the French pédant (used in 1566 in Darme & Hatzfeldster's Dictionnaire général de la langue française) or its older mid-15th Century Italian source pedante, "teacher, schoolmaster". (Compare the Spanish pedante.) The origin of the Italian pedante is uncertain, but multiple dictionaries suggest that it was contracted from the mediaeval Latin pædagogans, present participle of pædagogare, "to act as pedagogue, to teach". The Latin word is derived from Greek παιδαγωγός, paidagōgós, παιδ- "child" + ἀγειν "to lead", which originally referred to a slave who escorted children to and from school but later meant "a source of instruction or guidance"...........

We have found that 2 adsorptions are usually sufficient to get rid of all the autantibody, as compared to 3 or 4 using WARM. So there is less dilutional effect from residual saline in the red cells. As for the procedural dilution of the test serum by adding an equal volume of PEG, that's pretty much what happens if you were using PEG on unadsorbed serum. The Tech Manual notes that some have reported a weakening of antibody reactivity compared to other methods, and that some use 6 drops of adsorbed serum/PEG mixture instead of 4. We tested several spiked samples using PEG vs. WARM - adsorbed sera. We found equal or higher titers with the PEG sera (6 drops) and feel quite comfortable with the technique.
If you know where you're headed, you can do a serum panel, DATs, eluate and panel, autoadsorptions and crossmatches and get the blood out the door in less than 2 hours.

Our past and present lab computer systems (Sunquest and Meditech) won't let you allocate a unit if the retype has not been done. We do the retypes as soon as we enter them into inventory.
As with the others above, we haven't used retype stickers for years.

Our past and present lab computer systems (Sunquest and Meditech) won't let you allocate a unit if the retype has not been done. We do the retypes as soon as we enter them into inventory.
As with the others above, we haven't used retype stickers for years.

ALL of the advice here is very good, and I would take ALL of it, most importantly the part about getting to know your regional accounts manager (ARC"ese" for customer representative, customer service rep, etc.). And also that about being very specific with your questions, as per your needs.  
One nugget I would add is, as a former ARC customer and ARC medical director (ie, both sides of the coin), I would caution that experience with ARC can vary greatly region by region, as may be the case with any large, national company with multiple, regional stores, centers, etc. 
From my time on the hospital end, the reference lab piece was VERY important, as both hospitals where I worked saw a lot of complex patients with crossmatching challenges.  It might be a good idea to discuss this piece by conference call with the accounts manager and the IRL (Immunohematology Reference Lab) supervisor, to more specifically address whether your needs and TAT requirements can be met. Due to staffing, demand for services and other issues, IRLs may or may not have on site coverage after hours and weekends, and on call staff would need to be called in for these cases.  There is also the possibility of writing a contract with ARC that does not include IRL services if you are not convinced your needs can be met.
BTW, the "inside" slang for a former ARC employee is "FARCE".  So there--it's out! 

The point about warm auto-antibodies, even the ones that look exactly like an auto-anti-M, an auto-anti-Jka or a specific Rh antibody, such as auto-anti-e, is that they all tend to be mimicking specificities, and so, in reality, you might be fooling yourself by giving antigen negative units to the patient, but you will not be fooling the patient's immune system, and so the chances are that, in most cases, the antigen negative transfused red cells will last no longer than the patient's own red cells.
"Cold" auto-antibodies tend to have true specificities, but, even if you can find antigen negative units, the red cells will usually not last as long as the patient's own red cells, because the patient's own red cells are coated with C3dg, which gives them some protection from removal from the circulation, whereas the transfusion red cells have no such protection.
I agree with your Reference Laboratory - which, considering that is my own background, may not come as a surprise to a lot of people!

Malcolm, you need a hobby, this is being a little nit picky.    But then I guess it's now our job to keep things set folks straight.  I do think that the common term used on this side of the pond is either electronic crossmatch or computer crossmatch but I have to agree that electronic issue is probably more accurate.

I've always wondered how on earth people had the time and money (and slave laborer research assistants) to do this? How many other seed extracts did they have to search through before finding the dolichos, ulex, vicea etc that did something with certain red cells and not with others. And finding the best recipe for preparing it. What a colossal amount of tedious work! I have trouble just finding the second blue sock in my sock drawer. Happy Thanksgiving to all.
Phil

Good for you, Barb. A victory for logic and improved patient safety over the nefarious forces of penny-pinchers - how refreshing.