dgibaud

I know this is an outpatient preop, but I would certainly check to see if there is a transfusion history. If this patient received some A plasma or platelets recently you could see this pattern.

I was involved in looking for a lab-wide document control program about a year ago. Since that time it evolved into a "system-wide" search, and of course, the lab is no longer involved. For my money, the best program we saw was from a company called LUCIDOC. They seemed to be more laboratory friendly, that is, in generating a document life-cycle with automatic reminders for signatures, and all of the documentation required by the various accrediting agencies. Give them a call. They did a real nice demo for us over the web. Don

Since we've started gel testing we use the gel result exclusively to report the Rh status. As others have experienced, we get the occasional patient who was either Du (back in the olden days) or negative by tube testing, who now tests weakly positive in gel. We routinely call these patients Rh positive, give them Rh positive blood, and withhold rhogam. We haven't seen any problems, but our sample size is quite small. Is there a problem with our practice? Don

We use a "homemade" armband for outpatient transfusions and Rhogams. Contains the required information (name, hosp #, etc). Our patients also complain about wearing it for multiple days. I don't know how you get around that issue. Don

At our facility the patient presents with an "order form" from the physician. As long as we have a previous record of Rh type, and no evidence of ALLO anti-D, we give the Rhogam to the patient to take back to the physician office. The patient only needs to wait about 5-10 minutes. We do the workup (abo/rh/screen) at our leisure. We issue at our main site, and also 2 other satellite drawing sites. Don

We've been sending blood to our OR for about a year. We tried a couple "mini" medical refrigerators, but ended up going with a true blood bank model. The blood is issued via pneumatic tube with temp indicators from Williams Labs. I think they're easier to read than the Hemotemps. If blood is not used it is returned to the BB. If the temp dots indicate it did not exceed max temp then it is placed back in the BB refrigerator. This system works fairly well. I did all the validation studies to begin, but our BIOMEDICAL department assures me they will do alarm checks and the like at regular intervals. Don

You also want to consider the freshness of the screen vs. the panel cells. Some antigens lose strength as they age. Don

We use it at our facility for numerous orthopedic surgeries. It is performed by the OR staff and it's called the GPS system (gravitational platelet system). I believe the original work was done in California probably 10 years ago involving injections of platelet concentrates into subjects with tennis elbow. Supposedly the cure rate was around 70%. I have no idea what kind of validation the OR did or if they just started using it based on published data. I'm glad that it's THEIR procedure and not mine. Don

We also have the DH-4, but keep our plasma at -70C. It takes us about 25 min to thaw a unit.

One good thing is that everyone must do things the same way. No more "freelancing". You will still need tube methods for antigen typings. As others have said gel is an ultrasensitive system so you may need to do tube panels and/or xm's. It is certainly a more costly system when compared to tubes.

Many years ago some sites used the Du test to screen for FMH. However, it was estimated that a fetal bleed of about 50ml rbc would be needed for the average tech to recognize this as a positive Du. That's why the method is no longer employed. Don

Say a patient arrives at your urgent care medical center in downtown Chicago and reports that she just aborted in her apartment bathroom. She's seeing you to make sure she's not going to bleed anymore, but she's adamant that she won't go to the hospital that's 40 blocks away because she can't afford the cabfare, and her "boyfriend" doesn't want to wait. She doesn't know her blood type, and neither do you. She just needs to get back home. No previous records are availble. You know if you draw a sample and send it to the hospital for verification, it will probably take over an hour. Similar situation, Dutch Harbor Alaska. You've got a medical center, but the nearest hospital is hours away by plane. A storm is raging outside and you have a patient that might be a rhogam candidate. Do you wait for the storm to subside? Or...just do a quickie screen, give the rhogam, and be safe. Granted, these are unique situations, but these sound like a perfect job for a POC blood type. I'm sure there are more.

I can see application of this test in places that treat women who do not get much prenatal care (low income areas, planned parenthood centers, remote rural areas) where you might see them once and not again. There are other unique situations where patients might present where you don't have blood bank support. Don

We confirm ALL antigen types marked "historical". Why? Because I've been burned before. I just happened to discover the mistake prior to transfusion. Our supplier offers "confirmed" negatives (these units are actually typed) but due to cost we always get "historically negative" which are cheaper.

We give our physicians enough credit to know to order PREC on only very low likelyhood to be bleeding. I would guess that less than 5% of PREC ever get upgraded to T&S or XM. It's better than having an unexpected major bleed WITHOUT having a tube already in the blood bank, and it's better than having an "extra" mixed in with the hundreds of tubes from the other lab departments. Anyway, it's a system that has worked well for us in most cases. Don

We have 3 levels of service: T&S, XM and what we call a PRECaution tube. This is a no-charge BB test, which requires sample ID, phlebotomists initials, etc. It is held in the BB, mostly for our cath lab patients. The beauty of this order is that we keep costs and workload down, but know exactly where the tube is if blood is required. The PREC order can be upgraded to either T&S or XM if necessary. We LOVE the PREC order and wish more docs would use it, rather than performing unnecessary XM's. Tube good for 3 days then discarded. It's a good idea. Don G BB supervisor MidMichigan Med Ctr

The problem is that the accuracy of tests like the KHB is NOT very good. You might get a more satisfactory answer if you used continuous flow cytometry, but not many places have the luxury of having flow cytometry.The good news is that overestimation of FMH is not harmful to anyone (one could argue that getting multiple vials of RhIG is painful, but not harmful). Kudos for realizing that a FMH that high should result in an anemic baby. Sometimes you have to see the entire picture. However, what physician would reduce the recommended Rhogam dose based on the baby's Hgb level? The KHB isn't a great test, but at the moment it's all we have.

A nu mber of years back we transfused a unit w/anti-E into a lady we had not tested for E antigen. Our thoughts were the same as yours: there can't be enough antibody left in a red cell unit to do any harm. Turns out the lady had a nice mild reaction. Had a positive DAT for a few days and we couldn't ever really be sure there was any significant hemolysis. But...it DID cause some discomfort, and we realized that if something more unfortunate had happened we would be arguing from an indefensible position. We currently accept units with antibodies, but they all go to antigen-negative recipients. Better safe than sorry.

There probably isn't much gained in doing the antibody screen at 28 weeks, except in the case where you might find alloanti-D, or a different previously undetected antibody. Yes, extremely rare, but they DO happen. That's why I do the antibody screen at 28 wks. I'd rather not be surprised if/when they do a TYSC at delivery. Again, rare events, but much of what we do in BB is to prevent the rare from happening.

Our practice is to draw the rhogam workup, and then give the rhogam to the patient to take to the physician office for injection. We don't make the patient wait provided: 1. We have historical evidence that she's Rh neg, and 2. No evidence of allo-anti-D. Note, that doesn't mean she has to have a negative antibody screen on file, just no history of active anti-D. I've been doing this for more than 35 yrs, and I count 3 ladies that had allo-anti-D when we finally tested the 28wk sample. Make it easy for everyone if possible. For those without a history, we either make them wait till we determine Rh type, or they can come back with their armband on. Actually, as long as they have the armband WITH them, we don'e redraw.

Does the patient get a new medical record number when admitted to the larger facility? Doesn't this then cause an armband mismatch, or the possibility of one? We always get a new sample. Do the blood bank records (abo/rh, transfusion history, etc) transfer also? Something to think about when you have one computer system sharing a database with multiple sites.

We repeat the panel every 7 days, unless the antibody screen changes, OR antigen-negative units are crossmatch incompatible.

I use the CAP assessment as part of my overall competency tool in BB. We're a 275 bed hospital w/active heart and oncology programs. Usually there are 3 of us on days, with a rotating tech on afternoons and midnites. About 15 people are actually in the program. Yes, there is some complaining that the assessments cover areas we might not be doing (anticoagulants, preservatives for donor centers), but I think they need to have some understanding of these topics beyond what they learned in school. I allow them to use any texts, other sources, to complete the exams and require 70% as a passing grade. The CAP provides the ability to call reports and to actively monitor tech activity within the program (who's started, who's finished, what grade did they get?). It's not everything you need, but it fits in with the rest of my competency plan. I don't hand out wet samples, but I may give panel sheets, or some other "dry" antibody or other BB type problem. We've been on it for about a year now (chemistry only just started) and we like it.

Regarding the uniform procedure: It looks like it call for R2R2 cells (e-) cells, which make it problematic for me.

I've seen a demo of transfusion manager and though you won't need a specific "blood bank ID" band, the patient will need to be armbanded with a band containing a barcode that is read by the "transfusion manager device". We just started using Collection Manager and are experiencing some mild, but annoying problems. We have not made a decision on whether to seriously pursue implimentation of Transfusion Manager.