Malcolm Needs

I had my student work on our two patients some more - both women we thought had Anti-K along with their Passive D's have had K negative babies - they have not been transfused and pre-RhIg injection screens were negative!
 
I too looked at all the cells that were reacting and they are Bg positive.
3 more K+Bg- cells are negative.
BUT a couple K-Bg+ cells are not reacting!?!?!

Are you referring to the podcast "Kell Kills?" Did look at that and see that he took a lot of time to point out the correct nomenclature for the Kell Blood Group Antigens/Antibodies (and yes, I do cringe when I hear someone say Anti-Kell....however). And when I am teaching, I do go through this.....but the degree to which I try to get my staff to use the correct nomenclature, depends on the staff. When a Reference Lab Supervisor....yes, I expected them to call them by their correct names. When working at Hospitals where the staff was "Blood Bank" only, I at least "made an effort" to get them to use the correct nomenclature. But when working with Generalists (as I do now)....they are doing well to remember so many things in so many depts.; just to be able to get the work done, that I would seem foolish (and very pedantic) to keep harping on them about something like this. If they tell me they have an Anti-Kell (which they all do); I know what they are referring to and I leave it at that.
Also from the podcast.....saw that he discussed the McCleod Phenotype. I was fortunate at 1 large Hospital I worked at, to see one of those. But what really stayed with me was that I was very impressed because it was the Pediatrician who had requested that we type the patient for all Kell System Antigens (the child had CGD).
Brenda Hutson

 

You hit the nail on the head!  The K positive cells were also positive for Bg.  Went back and found D neg Bg neg K pos cells and they did not react.  Mystery solved.

"He's got a Kell" "A WHAT!?"  ;|
 
Anyway, way down on the screen on this, I forgot the subject!  Oh ... using Hemo specimens for BB tests.
 
Aside from the 'pendantics' (is that a word?) and interesting points about how reliable/contaminated these Hemo tubes may or may not be, I have a concern about the dilutional factor causing a false negative Antibody Screen/ID. 
 
Maybe I'm dating myself but I was told those little lavender top tubes used for Hemo contain liquid EDTA ... enough of which the hemo machine uses a calculation to 'correct' the values.  The pink top tubes used in BB have a 'dry' EDTA in them (concentrate sprayed on the inner walls) so the dilution factor is much less.  This was the reason presented for why BB needed to use pink tops while Hemo still uses lavendar tops when we switched to plastic.
 
No?

It's on bbguy (just put that into your search engine and it should come up) and her rants about people who call the antigen Kell, instead of K, and anti-Kell, instead of anti-K - just like me!!!!!!!!!!!!!!!!!!

To add another angle to this view ...
 
Has the patient EVER been transfused?
 
I'm thinking this because not only is that the first question I ask, but also because I have a tech in my BB who received 2 units RBC when she was a teenager.  When she was a student in college during her BB rotation, she tested her own plasma and found Anti-K.  Two children later ... no issues.  Now, 20+ years later, her Anti-K 'comes and goes.  It's possible it could show up now and then if her system becomes stimulated ... like maybe by an infection ... hmmm.
 
We forget that antigens are merely chemical combos ... sometimes those combos appear in nature ...
 
 

I believe the best solution are the remote refrigerators that are interfaced with Blood Bank systems (blood "vending machines").  They have been proven to be effective and safe.  However, they are extremely expensive.  My answer to OR would be "show me the money".  I would not want to sacrifice safety for their convenience.

I have tried in several Institutions to get the Techs. to say Anti-Big K or Anti-K1. I remember at one place that a Tech. yelled out to me in the Lab....Brenda, the patient just has an Anti-Kell. I said "WHAT" Antibody did you say they had? She then corrected herself and we all got a good laugh out of it.
You are correct that Nurse draws are "scary....."fortunately, there aren't many of those here (and most of them have to be witnessed by a phlebotomist who then places the label on the tubes). The phlebotomists may not have the same regard for specimen integrity as a Tech. would....but they do have "scared into them," the repercussions of drawing the wrong patient or mislabeling a specimen when it comes to the Blood Bank.....and where I have worked, they are written up "big time" for that.
Questions for you as you talk about your checks and balances:
1. Is the 2nd type you speak of; performed on the same specimen; or on a 2nd blood draw? Because if on the same specimen, that will not detect an error in the blood draw itself (as I am sure you know). It is that way here right now.....but after I finish my "current" project (new Irradiator); electronic crossmatch and a 2nd blood draw will be my next. I know the regulatory agencies have been moving towards that for years and I have worked places that do that.
2. The Blood Bank armband you speak of....is it just one of the typenex (or whichever brand)that is a manual process? Not saying that has "no" benefit; but unfortunately, most places where I have worked that use them (including my current one), do not use them 100% as intended (i.e. must be placed on every patient, at time of draw; while phlebotomist still in the presence of the patient)? Here, the armbands for pre-op patients are placed in a labeled envelope and placed on the patient when they come in for surgery. At another place I worked at, they would not place them on patients being drawn; not only for pre-op, but upcoming outpatient transfusions. Said the patients did not want to wear an armband around outside of the Hospital and they refused. To me, that is a "broken cycle" and is almost useless. Or does the patient have a locking Hospital band with a barcode on it which must be scanned for everything? And cool thing they were just starting to look at where I just came from.....palm scanning (no, not palm reading...that is for another Post). One of my Managers had that done in their ER.
Thanks
Brenda

   
Nope....we're just being pedantic! Ha Ha
Brenda

 

Brenda, (1) yes it's from 2 different draw times. I've always been surprised that for years typing the same spec twice was considered an acceptable way of "reducing" mis-ID risk. (2) I was just listing some of the options we have now that were not available many years ago, even though the application (like your Typenex bands) might fall short of ideal. And people always find ingenious ways of getting around the most well-intended and thought-out systems.  Like drawing an ER patient for several tubes, but not labeling all of them right away. The blood bank calls for a second draw to confirm the original type, so you grab one of the unlabeled tubes from that first draw, print up a label and slap it on and presto, it looks like it just came out of the guy's arm. I guess my point was that a tech would never do that, a phleb probably not, but a nurse...? Phil

Brenda, you're not being pedantic at all (but if you do want to get a rise out of Malcolm, just post something like "Anti-Kell rarely shows dosage effect with heterozygous cells..." - and Malcolm, I do the same!). We limit the use of non-BB specimens for the reasons you mention. I'd really like to think so, but I'm not sure our specimens are as special anymore, though. Back in the dark ages when med techs went up on the floors to draw the morning bloodwork, we rarely had specimen issues anywhere in the lab. We knew what tubes to draw, how much to fill them, how to mix them, how to label them, and the possible consequences of bad specimens - because we had to do the testing on them! If there was a problem with a specimen you had to go back up yourself and stick the patient again. I think, in general, we took a step down in quality when phlebotomy teams came on board because, although under the supervision of the lab, they were a step removed from test performance. Now nurses and nurses' aides do much of the blood drawing and we've seen a further reduction in quality. Their interest seems to rapidly wane the moment the inside of the tube gets wet, blood bank specimens included. We won't even talk about procurement and labeling from outreach areas and doctors' offices. Thank god we have the "2 typing rule", BB wristbands and barriers, computer safegaurds and the other departments have delta checks in place. Still, what we catch is only the visible tip of an iceberg of unknown proportions. I'm not saying that every phleb and nurse is careless or negligent, but I'm convinced that the further away from the lab you get, the fuzzier the specimen procurement practices become. The challenge for us and our institutions is to monitor, educate and tighten these up. That's my take (not pedantry but definate soap-boxism).

I see several people are channeling for John Judd here.  He was asked to fill in at the last minute for another speaker at the last AABB meeting and he managed to get in a reminder to not do the pre-warmed technique (which most of us define as a saline only tube method where reagent cells and plasma sample are warmed before combining and washed with 37 degree saline before addition of anti-IgG).  He used to refer to it as the pre-fried technique because people had a tendency to use ever warmer saline if they couldn't get the antibody to "go away" by using 37 degree saline.  Most of the missed antibodies in the study he published were due to the less sensitive technique of saline testing.  The thing is, you very seldom need to do it.  If you can rule out all of the usual suspects and get AHG crossmatch compatible units by a more sensitive method that is what you should do.  Save pre-warmed for patients with a really potent cold where you have no other choice and then don't "fry" the cells.  Then you don't often need to fuss with cold panels and the like because their cold antibody will probably jump out of the tube at you--or at least interfere with the reverse type.
 
Malcolm, note that I said "often".  (and I put the period after the quote marks like you Brits do.    )

Malcolm may say I am being "pedantic" for this (I just love having a new word to use....thanks Malcolm)....but historically, I do not like using specimens from any other dept. Reasons: Possible contamination and the fact that my experience tells me that phlebotomists are much more conscientious when they know they are drawing a specimen for Blood Bank than other Lab Depts. (not to say they are sloppy in other areas....just that there is an increased fear element for the Blood Bank).
That being said, I have "on rare occassion" resorted to doing it (i.e. if the Physician only wants a DAT and understands we are using the specimen Hematology used; or, if more specimen needed for ABID and cannot easily obtain it from patient....but would expect reactions to be consistent with work-up already started).
Brenda Hutson

I once had a gel heat block come unplugged at the back of the unit from people adjusting it forward with the cord caught on something. Fortunately we caught it before any positive screens were run (we repeated affected tests).  Almost worth having an alarm system considering the negative patient impact if not caught.  Fortunately it is rare.

I was mistaken about the blood types; one patient was O neg instead of A neg.  The latest cefotetan antibody came back positive. Patient is discharged and doing ok.  To be followed by Hem-Onc to taper the steroids.  I read one of Garraty's articles that said they don't know if steroids actually help or not but they are often given.
 
I think Grand Rounds is a good idea.  Seems like we might not have enough material for the whole presentation so I am thinking of "Current topics in Transfusion Medicine" and including this with the concept of using A plasma for emergency release instead of AB.  It would be nice to have something that people can easily refer back to over time rather than a one-time presentation though.  I started writing something up.  If it gets presentable I will post it.

That's a great response thanks Malcolm, and I look forward to reading the updated guidelines, many thanks
Tricia

My only caveat..............not if the patient is bleeding profusely.

With great pleasure Donna.
My staff were all running around with smiles on their faces that reached from ear to ear!
To quote Phil above:
But isn't this why we do it? My students all know the correct response to "What's the most fun a blood banker can have?" In unison: "Antibody identification!"

I don't know what is going on at the moment, but, in the last two weeks we have had an anti-Ch, an anti-Rg, an anti-Ge2 in a patient with alcoholic liver disease, a pregnant Oh, an anti-Jk3 for surgery, an anti-Yta in pregnancy and an anti-K+Jkb+Csa in a bleeding patient.
Keeps life interesting!

dcubed,
 
Just another thought regarding "rr Kk cell=1+strong".  Was this multiple examples of rr Kk cells or just one?  Pregnant women are notorious for forming HLA antibodies.  Frequently we see an occaional extra D .neg panel cell turning up positive.  The extra pos reaction could be "Bg" reactivity and could be the patient's own antibody or in the RhIg

With great pleasure Donna.
My staff were all running around with smiles on their faces that reached from ear to ear!
To quote Phil above:
But isn't this why we do it? My students all know the correct response to "What's the most fun a blood banker can have?" In unison: "Antibody identification!"

Did anyone else notice that Heat Blocks were listed under Hot Topics! 
 
The last heat blocks I had came equipped with digital temp read outs.  After doing all of the qualification testing to make sure the digital temps were accurate and reliable we only put a thermometer in the heat block when doing the monthly or semiannual (I can't remember which) 4 corner check.  That way we were not breaking off thermometers when reaching across heat blocks for some reason.  Never had any problems with those heat blocks.  Sorry but I can not remember the brand.

Very, very little Brenda (and I am probably being overly pedantic).
It is just that antigens cannot be either homozygous or heterozygous; only genes can be. Antigens can show homozygous expression or heterozygous expression, but they cannot be homozygous or heterozygous.
I agree with 99.9% of what you say.

Ok, so "now" you are being pedantic! LOL (would put a smiley face but still haven't figured out how to use this website; i.e. for replies). Ugh
Brenda
 

 

Then it might just be due to the E. coli infection.
Just to square the circle, as it were, if you have any of that batch of RhIG left, it may be worthwhile testing it with a couple of rr, K+ red cells, just to check that there is no anti-K in it. The things is, all humans, being humans, are a bit awkward and don't all react as they should! It may be that the others have adsorbed the immunoglobulin at a slower rate into their peripheral circulation (see that the anti-K may not have been detected), whereas this lady adsorbed it quite quickly, and so you were able to detect the anti-K.
Just a thought.

Townsend, I just cannot see what difference the cold agglutinin specificity makes due to the clinical signs and symptoms of haemolysis (with the POSSIBLE exception of anti-Pr - and I'm not convinced about that either, and, of course, anti-P in the case of PCH, but then the 2-stage DL test is better for that).
Of paramount importance is the thermal amplitude of the antibody.