Kip Kuttner

I am in a blood center with an IRL and am concerned about our reports to hospitals. The only clinical lab we have is for immunohematology. Currently each report is customized and typed. We do not issue a computerized report. I can see using standardization for a numerical answer but we report things like the antigen frequency, ways to serologically approach the patient in the future, and transfusion recommendations that, while not impossible to turn into a "LOINK", would be difficult. We will figure it out.

Hello David. Thanks for responding. Yes I have started wading through the site. However since I am basically lazy, I thought I would see what others are doing too! )

Have any of you dealt (successfully) with "Logical Observation Identifiers Names and Codes" coding especially for reference lab results? http://loinc.org/ (LO- OINK?) It is designed to be a "universal" result coding system for laboratories in the US subscribing to the affordable care act ACA. It is supposed to unify the result coding for all health care computers making test results readable by any health care computer. From what I understand, Health care Laboratories must implement this reporting system by the end of 2013 or face government penalties. For free standing blood centers with an IRL is there a module for reporting reference lab results or does a facility need to implement the whole system (Hematology, Chemistry, Coag, Micro, etc) to get at the immunohematology reference lab report codes? Thanks:confused:

I believe there was also a problem with excessive bleeding. In addition Aprotinin was frequently used with SD plasma which caused with Aprotinin sensitivity should a second procedure need to be done. I have (tried) to attach a nice review of the SD plasma history. The current product Octaplas, will probably be distributed through your blood supplier. However the cost is rumored to be 3x what FFP costs.

I do not have experience with the BloodXrad. However we do have a Raycell. We we were in need of a replacement for our Cesium irradiator. The Raycell is a nice piece of equipment however: 1) the tube needs to be replaced approximately every 7 years. 2) The power supply has a 5 year guarantee but ours needed replacement after 1 year of blood center use. 3) Parts coming from Canada may take days to clear customs. 4) Service personnel cover the globe so a 2-4 day wait before a service person gets to your site is not uncommon. 5) if your ground water exceeds about 72 F during the summer a chiller is necessary in order to stabilize the temperature of the cooling water. Likewise if the water is too cold, ( I do not know the lower limit off hand but it is in the specifications) the water needs to be warmed. 6) The chiller/warmer is noisy. Other than these shortcomings, the Raycell is well liked by the techs.

GilTphoto I think what you are seeing is most consistent with reality. However the OBs should be following their patients using doppler ultrasound when they know the patient is a high risk pregnancy. I am working on the best advice to provide the OBs for follow-up based on the lab work we do when a potentially clinically significant Ab is detected during pregnancy. I can tell them to follow with serial titers, and that is easy for anti-D and even anti-K because there are published cut-offs but as you have illustrated above, titers are not always predictive even for well characterized antibodies. And... as was mentioned above one titer is not often comparable to another.

Silly me... I can do the net search. I appreciate your help.

Thanks for the replies. Yes, we would do titers on abs that have shown to be clinically significant. I would hope that the same lab would receive samples for further titer so the method for getting the titer would remain consistent. A rise in titer suggests increasing sensitization. How much of a rise is cause for concern may debatable. For Rh, the critical titer is 16 or 32 depending on the facility (and I hope the actual titer procedure. Would others agree that a difference of two dilutions regardless of the antibody involved, indicates on-going sensitization? Malcom, I do not know if you are the site expert. However I am having difficulty downloading the BCSH guidelines. I get an error message "0.4 of 179KB - Operation could not be completed. Connection reset by peer" could there be an FTP server that is feeling ill? Thanks to both David an Malcom

There are guidelines for docs to use in order to manage pregnancies when anti-D is identified in the mom and titers a known. I have read (somewhere) that the significance of doing titers for non-D antibodies is not known. Does anyone have a differing opinion? For example if anti-S or anti-Wra is identified in a mom to be, would following serial titers provide useful information? Another way of asking the question is "If the titer of a non-D antibody goes up one, two or three-fold, is it significant? Thanks in advance for the feed-back.

Here is how I look at HTRs. My first thought would be a high titer anti-A in one (or both) of the platelet products, true there should have been a positive DAT. Could there have been an antibody to a minor blood group antigen in the platelet? True, there should have been a positive DAT. I doubt the cold would be responsible especially if it did not react at 30 degrees. Cold agglutinin syndrome can occur with cold reacting antibodies because the blood in the capillaries of the skin and extremities is at a lower temperature so the thermal amplitude of the antibody would be good to know. In addition, Garratty's book on immune hemolytic anemias says that fever, chills and acute renal insufficiency do NOT occur with cold agglutinin syndrome. Also, Cold agglutinin syndrome is a chronic condition rather than being acute, so I would think the donor should have a history. The patient history does not fit that of Paroxysmal Cold Hemoglobinuria. Bacterial contamination can be missed even with the QC culturing we do and it would have been helpful if the patient and unit had been cultured. Additional possibilities include improper handling of the RBC units prior to transfusion (ie storage temp) administration with incompatible IV solutions, administration under pressure or through an IV needle with too small a bore, malfunctioning blood warmer, and the incorrect unit going to the patient, to name a few. Sometimes these reactions are difficult to sort out. My .02

I talk with donors having a hematocrit over 50. The issue with high hematocrit/hemoglobin levels include dehydration, living at a high altitude, hemochromatosis, erythroblastic leukemia (rare) and multiple causes of polycythemia. In the US a blood center can obtain an FDA variance to distribute blood drawn for therapeutic reasons, from donors with hemochromatosis but not polycythemia. In addition, the platelet collection equipment software (®Trima) begins to have difficulty establishing an interface if the hematocrit is higher than 51. However there is no upper limit established by regulatory agencies. Be sure to discuss this issue with your medical director.

I did a quick literature search and found several articles describing an "apparent" auto anti- Jka in the presence of chlorpropamide, aldomet, and methyl esters of hydroxybenzoic acid. There was one report of a DAT negative auto Jka associated with a case of Evans' syndrome.

I think that finding "best practices" is best done by looking at the specific application. For example, look at transfusion and coronary artery bypass grafting or transfusion and knee/hip replacement. This way you should come up with more pertinent information. Transfusion indications have become more segmented because there has been a movement away from treating a transfusion trigger and more emphasis put on treating the patient. May patients without complications can avoid transfusion when the Hb drops to 7 or so while others especially with cardiac complications may need to be transfused much earlier. One respondent mentioned the references in the most recent edition of the circular. While some are 10 years old or older, those references still have relevance to practice today and make an excellent starting point. Massive transfusion protocols and the ideal age of blood for transfusion are still under debate. With regard to massive transfusion, current search is for the ideal ratio of plasma to rbcs in massive transfusion. The jury is still out on this issue. Regarding the age of blood, there is a huge debate in the literature.

You could try to speak With Pat Arndt in the American Red Cross Reference lab located in Pomona and see if they can set up an experience for you. If that does not work Dr. David Oh at the San Diego Blood Bank may be of assistance. Finally you could try Life Stream in San Bernardino. Dr. Rick Axlerod is the CEO, but you might try their asking for someone in the Reference lab to see if something can be arranged.

I regret, I am in Pennsylvania. If you are in northern CA you have more choices for blood centers. Are you in the Bay area? Also, Missyg has a great point. GW also has a nice review course.

In addition how you document a transfusion could come up at an AABB assessment when they review transfusion paperwork. If the paperwork is intended to document the proper patient was identified, the vitals were taken at the proper times and so on, Standard 5.21 probably applies: " At the time a unit is issued, there shall be a final check of transfusion service records and each unit of blood or blood componenet. Verification shall include: etc The Standards are written fairly broadly and take a bit to get used to in comparison with the checklist regs of CAP and JCHO.

You may be able to work out a rotation in a community blood center to see what goes on in a blood donor center. For some certificates, rotating through Donor screening and phlebotomy, product distribution, component manufacturing, viral testing, a reference lab may be adequate. It certainly would not hurt to contact your blood center to see what can be done. We take students in my center from time-to-time. The AABB at their annual meeting (which is in San Diego in October I think) has an all day SBB review before the meeting begins. I understand it is quite good.

Esther, If you are in the US, perhaps you could have any additional questions answered by speaking with the medical director at your local community blood bank. Most always, he or she will take some time to discuss this issue with you. It is not uncommon for me to receive calls like this, and I have a bit more time than many of the hospital blood bank doctors and technologists. Malcolm Needs has done a great job with his explanations though.

Hi, Platelets are activated in two steps. The first is that they aggregate. The aggregation phase can be reversed if the platelets are not pushed to the second stage of activation. The the forces of centrifugation cause the platelets to be activated to the aggregation stage. Microscopically the platelets go from a discoid shape to a spherical shape. By letting the platelets "rest" you permit the reversal the aggregation process and the platelets assume the discoid shape. Should the activation process continue, the platelets degranulate and will no longer function well to produce hemostasis. The reason for the label down probably stems from the production of platelets from whole blood. The label occupies a lot of real estate on the bag, and the label is not. The bags are gas permeable permitting the "release" of CO2, the product of glycolysis, out of the bag and for O2 (which is necessary for glycolysis) to be absorbed into the platelet. Having the bag label down optimizes the surface area available for this to occur while the platelet is "resting". This permits adequate gas exchange permitting glycolysis and maintaining the Ph of the plasma.

The goal for this type of sampling would be to interdict 100% of the contaminated units. However, the literature shows us that there are shortcomings with each available procedure for detecting platelet units contaminated with bacteria. There may be advantages to sampling the units twice. We have not detected the release of contaminated products using our procedure for platelet contamination QC though. There was an article published last month from MD Anderson in which the effect of low level bacteria contamination in platelets was reviewed. Basically the result was that because of the concomitant administration of antibiotics to some recipients of platelets and functioning immune systems in others the effect of low levels of bacteria in products on the outcome of the transfusion was minimal. (I am out of town and cannot grab the reference for you at the moment). I think information like that must be balanced against our compulsive desire to do everything perfectly.

Charter Medical makes the sampling device we sterile doc to our units.

Yes, platelets in the US expire 5 days after collection. We sterile doc a sampling device to the platelets so they can be entered in a "closed" system.

When the BacT Alert bottle is positive, we quarantine all of the products from the collection including RBCs and plasma, plate the contents of the bottle AND the platelet product that was positive. If none of the subcultures grow, we consider the initial result falsely positive. We sample our platelets 24 hours after collection, taking 4 ml for aerobic and an additional 4 ml for anerobic culture. That process came out of the Passport study, designed to see if products could be held for seven rather than five days. (This study was stopped when the number of true positives at 7 days exceeded those positive at 5 day) The products are released 48 hours after collection if all results are negative, but the bottles are held until the expiration date/time of the product.

We collect about 15,000 SD platelets per year and have approximately one false positive per week. True positives are in the range of 1-2 per year.

It also seems to work OK with Safari 5.0.1 .