Malcolm Needs

Many have mentioned what they did to study (Transfusion, Technical Manual, Issitt, Daniels, Last Chance Review, etc.) and I want to add some additional items about what I did to study.
1)  I found Malcolm's educational powerpoints on blood group systems on this web page to be very helpful. (Thank you so much for sharing.)
2)  I read lots of abstracts and some articles in the journal "Blood" (many of them are open content, all are after one year).  Particularly about coagulation disorders and treatments and hemolytic anemias.
3)  The web page "Blood Bank Guy" has lectures and quizzes and this helped me.
4)  I am a visual learner.  I would do searches and look for Google Images (it is amazing what is out there, like pretty cartoons of Platelet glycoproteins, Complement cascade, red cell antigen structures) and then print them out and (literally!) cut and paste them into a study notebook.  Then I'd add my notes.
5) practice the "Blood Bank Math" problems <repeat>
 
Linda Frederick

I agree that doing a DAT on every patient is almost certainly wrong but never underestimate the power of a DAT - for Haematologists move in mysterious ways !
I used to tend the needs of 4 Consultant Haematologists who all used completely different (and secret) criteria for selecting which patients required a DAT.
The only thing they had in common was their immense gratitude when, based on other serological findings, we performed a DAT which gave an unexpectedly positive result - they appeared to find this extremely useful in their diagnosis and treatment - even though they never explained exactly how.
It seems a relatively cheap and easy way of keeping an important and fairly benign alien species happy.

I hate to be even more pedantic than normal (if that is possible) profbaud, but how do you know that you have not missed an antibody for 18 months?  If the tests are negative, then there may still be an antibody present, but you would not know, as the tests are negative.

Actually, it seems that the OB folks in our area read about a baby developing HDN from potent anti M.. We have been asked to distinguish between an IgG and IgM anti-M to decide how to proceed with the serological evaluation of the pregnancy.
 
In our case DTT treatment has not eliminated the reactivity at IgG.  Thus the concern for a mixed IgG/IgM antibody.
 
I was thinking that our anti-IgG reagent was made to the determinant on the Fc region of the IgG and should not react with IgM monomers formed after DTT treatment that might be hanging on to the RBC membrane after washing and the IgG reagent is cross- or non-specifically reacting. Strange things seem to happen when the antibodies don't read the textbooks. 
 
Another possibility is that the IgM was not completely disassociated by the DTT and there is residual pentamer on the RBC causing the residual reactivity.  I have rarely seen a 4+IS reaction with an anti-M.  When DTT treated, 1-2+ reactivity disappears in our lab. So we are going to cook the antibody a little longer in DTT.
 
Thanks in advance for any other suggestions.
 
Update:  Cooking longer (2 hr and 3 hr) did not result in negative reactivity. It is 1-2 +.  It seems to me this is a mixed IgG/IgM anti-M antibody so I guess I will recommend serial titers to OB.

Hi Mabel (and other friends on this site), although I will not be at AABB, a very good mate of mine named Dave Bruce is going, and will be presenting a poster entitled, "Successful ABO incompatible kidney transplantation - using Bio-Rad column agglutination technology to assess the risk".
If you happen to see him, please say hello and make him feel welcome (as I am certain you would anyway).

Oh that it were that simple!
 
Unfortunately, because the A, B and H antigens are not direct gene products, but rather, they are the result of actions by transferase enzymes (that are, give or take some post-translational changes, the direct gene products), it is not.  If you can get hold of a copy of the third edition of The Blood Group Antigen Factsbook by Marion Reid, Christine Lomas-Francis and Martin Olsson, there is a section in there (pages 32 to 42) that shows just how complicated is the genetic background to weakened forms of the A and B antigens, and why your suggestion (great on the face of it) would not work in practice.

We do the same thing here. One time I had to call five out of state hospitals to get the complete history on a patient. Having all that information was well worth it!
 
On a personal note, I have often said that if I ever developed an antibody, I would get a medical alert bracelet. I wonder why that is not a routine thing. That information is certainly as important to a patient's treatment as information regarding allergies, etc.

In the Netherlands since the recent guidelines, we have to select Rh fenotype compatible for al patients that have a (Rh, Kell, Jk, Fy Ss) antibody, to prevent these problems.
 
Maybe I have mentioned this before but we have now a almost nation covering database for the registration of allo antibodies, TRIX. Before transfusion a hospitol have to look in that system (mostly done by the LIS system) to see if the patient is known with antibodies. Since the introduction of the database I have heard a lot of stories (and seen publications) about patients with undetectable antibodies. I think the UK and the USA for sure are to big (to many hospitals) for such a system but in the Netherlands (100 hospitals) it is working fine.
 
Peter

Both ficin and papain work well for adsorptions. We have routinely used ficin in our reference lab for decades, both for antibody ID and adsorptions. And both enzymes can be used as constituents of ZZAP. A couple of years ago I compared cysteine-activated papain and ficin as constituents of ZZAP, and the volume of 1%ficin used in ZZAP. In the AABB Technical Manual, the ZZAP recipe calls for twice as much 1% ficin as 1% papain without explanation. I found there is no need to use 2x the volume of ficin. I suspect there may have been some issues with the activity of ficin some years ago. We prepare and standardize our enzymes. Both the ficin and papain for this study were purchased from Sigman-Aldrich.  ref: Leger & Garratty. Comparison of papaina and ficin as constituents of ZZAP for adsorption using allogeneic RBCs to remove warm autoantibodies for detection of alloantibodies (abstract). Transfusion 2011;51(Suppl):173A. 
 
Gina Leger

Welcome to this wonderful site richmond.
 
It could be an anti-A1, a "cold" auto-antibody, a "cold" alloantibody, or a mixture of any of these!
 
One way to test if an anti-A1 is present is to test the patient's plasma against about 3 red cell samples known to be A1 and against 3 red cell samples known to be A2.  If the tests are positive with the A1 red cells, but negative with the A2 red cells, you have probably got (at least) an anti-A1 (but, as long as it is not reactive at strictly 37oC, it will not be clinically significant).
 
In the case of an A2B individual, however, there are very few H antigen sites available on the red cells, and the chances are that your patient may well have produced an auto-anti-HI.  There is no easy way of proving this, unless you have access to either group O cord blood red cells or group O adult ii (both of which, to all intents and purposes, will lack the I antigen), and to Oh (Bombay) red cells, which will, of course, lack the H antigen.
 
That having been said, you can almost prove it by testing the patient's plasma against red cells expressing a variety of ABO types.  Those that are A1B will react weakest, and up to group O red cells, which will react the strongest.

What is this patient's Rh phenotype?
(DIV could also look like a normal D+ and make a nice anti-D)
Has she received any blood or platelets in the last 4 months?

We have in place the following:
1. If the patient exhibits signs/symptoms related to transfusion reactions (there's a list), there is no choice ... the transfusion is discontinued and a Transfusion Reaction Investigation is ordered.  Period. 
This is because the transfusion is under the license of the BB Medical Director who is thereby responsible for it.  Besides, if MDs have the powers to 'instantly know' whether the symptoms are due to the transfusion or not and that the blood was completely compatible or not causing any allergic, TRALI, Overload, etc. without any testing/rechecking/investigation, then  why do we need the Blood Bank investigations at all?  It is safer to stop and do the investigation than to rely on a variety of MD 'instincts'.  As much as they like to think they are, they (especially the residents) prove over and over again that they are not the experts in these matters.  (e.g. some of them are not aware of the symptoms or how to treat TRALI.)  I always think about 'how would this look in court?'  The only exception is 'Hives Only'.  If this happens, the infusionist is instructed by SOP to pause the transfusion, see if the hives subside, confer with MD to see if they want to administer medication, and then continue the transfusion.  
2. When a Transfusion Reaction Investigation is ordered, a specimen is drawn that becomes a) the 'Post Reaction' specimen for comparison studies (color, DAT, etc.) and the new pretransfusion specimen for subsequent transfusions.
All units that were crossmatched with the original specimen are released (i.e. not allocated to the patient anymore.) (n.b. we are on a BB Band system so each specimen is a separate entity) During the investigation, no units are issued unless the attending MD documents that there is a life/death situation where only the continuance of the transfusions will sustain life.  We haven't had this happen yet, but when it does, we plan to issue the prior compatible units with this documentation ... not sure if we should call this 'Emergency Release' or not ... now that I'm focusing on it, we probably should.

I agree that nothing should be given until the reason for the reaction has been resolved, except in life-threatening circumstances. Whatever the cause of the reaction, the fact remains that there has been a reaction and, until the cause is resolved, there is every chance that a further transfusion may cause a further reaction and exacerbate the situation.

Strangely enough, I am at the IBMS Congress in Birmingham (UK, not Alabama) and Jill Storry gave us a fantastic update on the MNS Blood Group System just this afternoon.
It is still VERY rare for anti-N to cause any such problems, but I just wonder if 1) the anti-N may be a mimicking antibody directed against another MNS Blood Group System antigen or 2) there may be an antibody present directed against an antigen not expressed on either screening cells or panel cells, but expressed in a heterozygous state on one of the units that was not detected by your cross-match, but which WAS detected by the patient's immune system?
The other thing I would do, as the DAT is positive by anti-complement only, is to request a clotted sample, and do a full work-up on that, just in case the anti-N is a red herring, and you have something really nasty there, like an anti-Vel (particularly as the reaction was so sudden).

Hi KAPMT, and welcome to this fantastic site.
Yes, there are a knowledgable bunch of people on here, all willing to share what they know, and I have found their posts invaluable.

Being a tech specialist is an interesting position. The technical stuff, I have found, is probably the easiest portion of the job. Working with and advising other staff, the the rainbow spectrum of
personalities encountered, and becoming more intimately involved with regulatory issues and CE
are the parts which I've found most demanding. Really, good luck to you. Remain humble, and regard
every person with whom you work as someone who can teach you.

Sorry to come late to this thread, but I have been trying to find a particular paper that may be of interest in this discussion, and I had an enormous amount of trouble locating said paper. Finally, today, I found it - on my desk, under a load of other things. Memo to self - clear up your office more than once a year!
Anyway, the paper is:
Jain MD, Cabrerizo-Sanchez R, Karkouti K, Yau T, Pendergrast JM, Cserti-Gazdewich CM. Seek and you shall find - but then what do you do? Cold agglutinins in cardiopulmonary bypass and a single-center experience with cold agglutinin screening before cardiac surgery. Transfusion Medicine Reviews 2013; 27(2): 65-73. http://dx.doi.org/10.1016/j.tmrv.2012.12.001
It is well worth a read.

Sorry to come late to this thread, but I have been trying to find a particular paper that may be of interest in this discussion, and I had an enormous amount of trouble locating said paper. Finally, today, I found it - on my desk, under a load of other things. Memo to self - clear up your office more than once a year!
Anyway, the paper is:
Jain MD, Cabrerizo-Sanchez R, Karkouti K, Yau T, Pendergrast JM, Cserti-Gazdewich CM. Seek and you shall find - but then what do you do? Cold agglutinins in cardiopulmonary bypass and a single-center experience with cold agglutinin screening before cardiac surgery. Transfusion Medicine Reviews 2013; 27(2): 65-73. http://dx.doi.org/10.1016/j.tmrv.2012.12.001
It is well worth a read.

Thanks for the responses.  I've discovered over the years that blood bankers love to live in the land of "What If".  You can be confident that I own a large home right in the middle of that land.    
 
I'm finding that patients are taking a more direct hand in their care and are much more knowledgeable than they were 30 years ago.  While info from a patient should be confirmed if possible, much more often than not they are reasonably correct if not complete in their info. 

We had a case recently where a patient came in through the ER, she gave the nurse an Antibody card for a Jka that was identified years ago in Texas. When we called to get more info we were told that the patient was not coherent and no family was available.  We did the screen (positive), and antibody Id and found a E, K (no sign of the Jka).  2 units were set up(E,K,Jka neg) and transfused.  The next day they ordered 2 more units, a nurse from the floor called to say that the patient was insisting she had another antibody card that she could not find.  I spoke to the patient and she told me she had 2 cards from different hospitals, she was also able to tell me all (or at least several) of the hospitals she had been transfused at.  I proceded to call all of them and found another hospital in Texas that had identified E, c.  We antigen typed the units she was given and 1 was c positive.  Post transfusion had a lovely c.
 
Morale of the story...Always listen to the patient....

I would antigen type the patient. If K negative, we would transfuse with K neg units (easy enough to find them). We would probably add the Anti-K to his account with a note that it came from the patient.
A couple years ago we found an Anti-E and Anti-c on a patient and prepared compatible units. When we were getting ready to issue them, the nurse called and said the patient would like to speak with us. I went up and she told me that she had "antibodies, but doesn't know what that means, and she had a horrible reaction many years ago". She insisted I call the hospital where she received the blood, even after I assured her that we found the antibodies. I called the hospital and they had Anti-E, c, and Jka. WHOA!!! Ever since that lovely lady was insistent, I listen to patients.

Hm, that makes it sound like I wouldn't err on the side of safety for other blood groups, but that isn't what I meant!!!!!!!!!

Sorry to come late to this thread, but I have been trying to find a particular paper that may be of interest in this discussion, and I had an enormous amount of trouble locating said paper. Finally, today, I found it - on my desk, under a load of other things. Memo to self - clear up your office more than once a year!
Anyway, the paper is:
Jain MD, Cabrerizo-Sanchez R, Karkouti K, Yau T, Pendergrast JM, Cserti-Gazdewich CM. Seek and you shall find - but then what do you do? Cold agglutinins in cardiopulmonary bypass and a single-center experience with cold agglutinin screening before cardiac surgery. Transfusion Medicine Reviews 2013; 27(2): 65-73. http://dx.doi.org/10.1016/j.tmrv.2012.12.001
It is well worth a read.

Fresh sample for us on admission. Over the years, I have seen too many patients answer NO to the standard questions and found they have recently been transfused in another hospital "Oh, I though you meant here in this hospital." I have never run a retrospective risk assessment on it though. Might be one for when I am short of work (LOL).
Cheers
Eoin

The only thing that I would say is that not all antibodies develop at the same speed.
Just because there was, for example, an anti-D present when the pre-admission sample was taken, does not mean that another specificity, for example, an anti-Jka, may not have developed by the time the patient comes in for the surgery.
Personally, I would want a fresh sample to test upon admission.