Malcolm Needs

Sounds good to me! I don't think there is anything else you could do at the moment, except, as you say, give R2R2, K- as a precaution. Ficin works just as well as papain for what I was saying. :D:D:D

The first thing I would do would be to test the patient's plasma/serum with papain-treated red cells. Apart from some very rare cases of extremely avid antibodies, the Ch and Rg antigens are desroyed by the action of papain, but at the same time, papain will enhance the reaction between anti-e and the e antigen. I would also type the patient for other antigens, M, N, S, s, Fy(a), Fy(, Jk(a) and Jk( for two reasons. Firstly to see if there are any mixed-field reactions, showing that some of the red cells from the transfused units are still present (it is extremely unlikely that the units given would be exactly the same phenotype as the patient). Secondly, to see what other antibodies the patient could make in the future. Certainly, it is doubtful that an anti-Ch or an anti-Rg would have caused all three units to have "disappeared" from the patient's circulation (sporadic reports of "transfusion reactions" caused by these antibodies suggest more of an HLA-type reaction, rather than a delayed haemolytic transfusion reaction), but I wonder if there may be another cause for the units to have "disappeared" so quickly (if, indeed they have), such as a chronic bleed, compensated by an active marrow. I wonder if you could tell us what the underlying pathology from which the patient is sufferring to require transfusions so often? This may give a clue. All of that having been said, if we have a patient who has anti-Ch or anti-Rg, we would tend to give them Rh and K matched blood in any case, just so that they are not stimulated to make further atypical alloantibodies. I have recently read a paper that stated 20% of patients who have produced one atypical alloantibody go on to make further antibodies when transfused, but almost all of these had a specificity within the Rh Blood Group System (C, c, D, E or e) or were anti-K. Only a very small minority produced antibodies directed against antigens in other blood group systems. I hope that helps in some small way. :):)

Thanks conwaysbb. I think that it is vitally important in such a case to differentiate between a delayed haemolytic transfusion reaction causing a less than expected increase in haemoglobin and other possible causes, such as your patient's disease state. A positive DAT alone after a transfusion, even if the DAT were negative prior to the transfusion, is not diagnostic of a delayed haemolytic transfusion reaction. Nor is a positive DAT and a less than expected rise in haemoglobin. The former could just be what George Garratty terms a delayed serological reaction (where tests such as the DAT become positive, but there are no clinical sequelae for the patient). The latter may be a combination of this and a less than expected rise in haemoglobin due to the patient's disease state. If it were the latter, then you would still need to keep the patient in for a longer period, and perform all the extra tests, but it might well prove that the transfusion was coincidental, rather than causitive. :confused::confused:

Oh, I agree, that is what you should do, but I would still put in a strongly worded and well-argued complaint that the kit is NOT testing the proficiency of the entire test. :mad::mad::mad:

I totally agree. Thanks Cliff. :D:D:D:D

Well yes, obviously for tests like an FMH and a KB, but I (and I think Peter Issitt) was talking about a serological test. :)

I would totally agree with what you say in the last part of this post. One only has to think of the number of anamnestic responses to a weak anti-Jka in the literature. What kind of reaction was it? Was it a full-blown acute transfusion reaction with rigors, dark/black urine, etc, a lower rise in Hb than would be expected, or what? I ask out of interest, rather than trying to catch you out (in case it reads like that). :confused::confused:

There was a survey done in the UK a couple of years or so ago, which raised some horror stories about observations during transfusion. One that stuck in my mind in particular was of a neonate being transfused in a side room, with no observations being done (and, of course, the poor little thing couldn't shout if he or she was feeling unwell). I know babies don't have their own antibodies usually (although some are born with their own ABO antibodies), but that does not mean that they have not got unrecognised maternal antibodies in their circulation, or that they cannot become over-loaded, etc, etc. :eek::eek:

In at least one of his three editions of his book Appkied Blood Group Serology, Peter Issitt wrote that microscopes should be banned from a Blood Transfusion Laboratory. I agree with him 100%. :):)

My immediate thought is, why are they sending out samples like this? The DAT involves washing, and always has done, unless it is being performed in column agglutination technology, in which case it usually involves centrifugation, followed by resuspension in the chosen medium, to the chosen concentration of red cells. If they want to ask you to perform a realistic test, and that, I would have thought, is the whole point of the test, then send out a whole blood sample, with the (presumably) IgG antibody sensitising the red cells and in the plasma; otherwise, what are they testing other than the AHG? :confused::(:confused:

Hmmm, not sure about that; I probably have many years more experience. I was weaned on the stuff!!

A true tour de force!

We still use this method occasionally in my Reference Laboratory for both antibody identification and cross-matching, if we suspect that the antibody is LISS dependent. Do not forget that this was not only the method of choice for many years before LISS and gel technology were invented, but was virtually the only method available - and we didn't kill hordes of patients. It is, it is true, not as sensitive as LISS and/or gel, but it is sufficiently sensitive to detect clinically significant antibodies (by that, I don't mean all antibodies that have the potential to be clinically significant in the future, such as a weak reacting anti-C, but those that are clinically significant in the patient at the time). You may boost the odd antibody, but that will not kill the patient, and will make it a darn sight easier to detect the next time! You will find this technique in virtually any old text book (pre-LISS and gel) that gives techniques. :):)

Right, I've checked some old notes, and I was more or less right, if the patient has had colloids or crystalloids prior to transfusion. Apparently, it depends upon the molecular weight of the colloid or crystalloid as to whether they stay in the patient's circulation (and for how long), whether they go out into the interstitial fluid, or how quickly they are excreted. The molecular weight influences the "suckability" (an anaesthetists word, not mine) of the fluid, as to whether fluid comes into, or goes out of the circulation. As a result, you should wait a little longer to let the whole thing settle down, so that you get an accurate Hb and Hct. Though I say it myself and shouldn't, not bad for someone who was awash with ethanol the other night!!!!!!!!!! :D:D:D

I'm not absolutely sure of my facts here, as I am just back from a wedding, and perhaps, cerebrally, not quite at my best (the champagne flowed), so I'll check properly tomorrow, but I think that this is not so much to do with the red cells being sequestered by the spleen, than the fluid being returned to the peripheral blood circulation from the interstitial fluid, and the deeper blood circulation, because, if a person requires a transfusion (or, at least, if a person requires a transfusion for massive blood loss), the peripheral blood circulation, largely, shuts down. As I say though, I am writing this through something of a haze, and will check my facts tomorrow. :tongue::tongue::redface::tongue::tongue:

Thanks Marilyn. I think GBS was right! We call it a FBC (full blood count). :)

Sorry, but being English, I'm not familiar with the term H&H. Please could you explain? Thanks! :redface::redface:

Actually Eoin, I don't entirely agree with this comment either, but for a different reason. There have been occasions when I, and others, have replied to threads/posts from donors or patients (lay people, if you will) who have asked questions because they are worried about something - like the lady who was rpegnany and worried about her anti-Cw, and the other lady who had a father who was HBC+, and who was worried as to whether she may also be HBC+ through birth, but wanted very much to donate blood. I think that, not only are these reasonble questions, but that it is our duty (and pleasure) to answer such questions and, I hope, reassure such people. :redface::confused::redface:

Yes, I think I might have told them to "expletive off" too!!!!!!!!!!!!

Sometimes, the NHSBT gets complaints if we take too long sorting out the specificity of an antibody and then providing cross-matched blood from a sample from a hospital who send it in because they cannot sort out the specificity of the antibody themselves and cannot cross-match the blood even when the antibody specificity is sorted and when provided with antigen negative blood - but we can live with that. Yesterday, however, I heard of a real goody! One of my colleagues (at another Laboratory) received a sample from a hospital requesting 4 units of cross-matched blood as soon as possible (always useful, as what does ASAP actually mean). There was no telephone call from the hospital. Anyway, they dutifully got on with identifying the antibody, cross-matching the blood and sending over to them. They then got an official complaint because they had done the work too quickly and sent over the blood before it was required!!!!!!!!!!!!!! Some people you just cannot please. :angered::angered:

I've used NEUTR-AB, and whilst there is no doubt it is "good stuff", I have my doubts that it only neutralises IgM. I think it also neutralises a certain amount of IgG. :confused::confused::confused:

Don't you just love 'em - and she will be teaching others! :eek:

I'm sorry to make light of a very serious situation, but (there is always a but) shouldn't it have been the knitting mills that held on by a thread???????? SORRY! :eek::eek:

It's almost the same in the UK John, except it's 12 weeks here.

Very good point! :):)