BankerGirl

I had this (almost) same situation many years ago, only it was the patient's roommate who finally said to me,"Honey, I think her family would appreciate it if you could waker her up, but she hasn't woke up once in the week that I've been here." The patient seemed to be snoring and everything! Her snorts would change when I (gently) shook her, just like my husband's do. I never realized that patients in a coma could snore! Unfortunately the patient died three days later.

OK, maybe 1/2 of a RC unit. If you figure 1 vial or RhIG is good for a 30 ml bleed, times 11 vials of RhIG, that is roughly 300 ml of fetal blood with an extra one for good measure. And yes, the baby was born alive, but with a 4.0 gram Hgb. The baby is now 1 year old and is apparently normal now, although she did have SERIOUS problems initially, and nearly died several times. We consider it a miracle that she survived! And three months after delivery, the mom had a negative antibody screen, as well.

One of our generalists' daugher-in-law had a massive fetal bleed which required 11 vials of RhIG to treat. We assumed her reaction was due to the large amount of fetal cell destruction occuring in vitro, as it calculates out to the equivalent of about 1unit of red cells. This makes me wonder if she received RhoGam or Rhophylac (she delivered in another facility). I have never heard of this issue before, and COMPLETELY AGREE that this should be a HUGE warning in the package insert!

My favorite mottos: CYA... Cover Your *** When in doubt, send it out and You never know who is listening, so you better be sure you don't say anything you wouldn't want someone else to hear.

So for those of you who discover problems, how do you proceed with audits? Do you perform them more often, concentrate on the "offending" person/unit... I have recently begun performing the audits, since it "takes too much time" for our Care Management department (like I have the time!) and we have horrible documentation, especially in the critical care units. Looking at the documentation in the past, we seemed better because Care Management did not count the ones where the documentation was incomplete. Yikes!!!!!!

I have also struggled with what to do with anti-D results on nearly all of our Rh neg moms since changing to gel. One suggestion I received was to do the antibody screens in tube so we do not detect the antibodies in the first place, but I have been loath to do this, as this may be perceived as inconsistent (using a less sensitive method selectively). However, we have also been getting several positive screens (with non-OB patients) that we waste hours working up, only to find that they do not identify anything in gel, and are negative using our tube panels. In these cases we report the tube results, so isn't this sort of the same end result? My questions to you experienced gel users are as follows: 1. Has anyone used this type of selective method for different patient populations? 2. If so, what have your inspectors said about it? 3. For those of you who have said you use a different code for anti-D due to RhIG, have you had any feedback from inspectors? I really would prefer not to perform AHG crossmatches on every pregnant Rh negative patient!:cries:

I don't understand CLIA's reasoning on this issue. Why wouldn't the gel pick up an ABO incompatibility? You are still mixing the patient's plasma with the unit cells, and regardless of the IgG, there would be a reaction if there was an ABO incompatibliity. This would still cause the cell complexes to remain on top of the gel, regardless of what was IN the gel. :confused:That being said, validation may still be the way to go.

When my youngest daughter was 2 my husband took our girls to my inlaws cabin at the lake. Being 2, she wasn't very good at keeping her mouth closed, and she got Giardia from swallowing the lake water. I called the pediatrician's office on a Friday afternoon to report that her O & P came up positive and the nurse said that our doctor was out of the country. The physician on call wanted the O & P times three, because that is what she always ordered. I told the nurse how ridiculous that was since we already knew from the first specimen what the problem was. The nurse calmly said,"Well, she didn't say that I couldn't call the medicine in NOW!" I really loved that nurse, and I "forgot" to collect the other two specimens. I swore I would never see that pediatrician for anything ever again. Fortunately, she (the doc) left town a few years after that.

Malcolm, Like I said, we had no way of knowing. And I had not considered the cannibalistic aspect! If I remember, we did perform occult blood testing, but I cannot remember what the results were. We also had a chat with the physician after that evening.

We once had a family that went to the grocery store and bought a package of diapers. When they were unpacking them at home, there was (they were sure) blood on the package. They were sure that it was human blood, even though they bought several packages of meat that were obviously bloody, and they wanted proof so they could complain to the store. They brought the diapers in for us to test to see if it was, indeed human blood. When we told them that we had no way of telling what species the blood was, they said "the doctor told us you could." They were very disappointed with us.

Malcom, We just gave the ITP patient the RhIg 10 days ago. I did not do the workup, as it was my day off, and I can't find the panel sheets just now, but it would be interesting to see if there is any difference in the reactions with the Rh positive cells, versus the Rh negative ones. You have me currious now, so I am going to have to find out what happened to those panel sheets!

We have had two such patients this month so far (a very rare phenomenon for us!). The first was a surgical patient with a history of blood transfusion in Germany, and the second was a case of ITP-treated Rh Immune globulin. In the second case, the patient required a crossmatch four days after the RhIg and, surprise, the IAT and DAT were positive. The antibody ID came out as a clear anti-D, but what surprised me is that the elution showed a pan agglutinin, not anti-D. I guess this goes to prove that you can't always predict--which is why we do the testing, huh?

I just got done working up a new patient crossmatch where the patient forward typed an O neg and backtyped an A neg. I got a w+ reaction with anti-A,B, but could not get anything to come down with anti-A, even after refrigeration. I called the doctor's office to ask for a patient history and the nurse said his history was unremarkable. After further investigation she found a note that he had received some sort of transplant and prefered to have his care done at another facility. I called the other facility for their help. It turns out he had a BMT a year ago and his type went from A pos to O neg. Well, this explains everything! Apparently a bone marrow transplant is "unremarkable" now.

I agree whole-heartedly with the comments about Ortho's 0.8% suspensions. We had so many problems with weak reactions that did not ID an antibody, that I contacted our reference lab and they suggested that we use 3% cells and dilute them daily. We even went a step further and use our "other" manufacturer's screening cells and we very seldom have problems with fuzzy antibody screens. My question is for those who say they repeat these in tube (LISS or PeG) and wonder if getting a negative reaction in tube is enough, or do you perform the gel panel first and then do the tube screening. We have had 98% or our Rh negative Labor and Delivery patients show weak anti-D in gel that we do not see in tube. What are everyone's thoughts on using tube only for these patients? One of our Techs didn't think the AABB inspector would go for different methods for different patients.

Yes, we automatically crossmatch two units, unless it is an outpatient who will not be transfused on that admission. Our policy states that a type and screen will be covered by two units withing five minutes of the request, and we cannot do an immediate spin crossmatch for positive antibody screens.

We have a lung cancer patient who was typed twice in 2008 as O Negative by two different techs. When she came in two months later she typed very weakly O Positive by two different techs. We decided to transfuse her with O Negative again, since that was her history. Since that time, her anti-D reactions have gradually increased in strength to where she is reacting 4+ with the antisera. Nothing has changed during this time--reagents, manufacturers, procedures--nothing. The doctors office says she is not on any "strange" drugs that would cause this. I have heard of antigens weakening with age/treatment, but can anyone come up with an explanation for this? We finally changed her blood type and are now transfusing O Positive red cells with no negative consequences.

We use glass tubes and have noticed this with only anti-D when we perform our daily QC. All other reagents seem to be fine. If anyone gets the answer, let me know. We also spin for 20 sec.

We have a Dr. Payne, as well. He is a Urologist. I think these doctors should be required to change their names!

Thanks for the suggestions Brenda. I was trying not to get too bogged down in the details, but it turns out that the patient had multiple transfusions at several hospitals across our state. The Red Cross reference lab had worked her up for another institution and had her phenotype on file. They had actually identified all four antibodies previously, but the S and Jka had become non-detectable by the time she came to us. The antibodies we had identified were anti-E and anti-M, and we all know that M is supposed to be IgM and thus, not clinically significant, but in the end, she had developed an anti-M that appeared to be IgG specific. ARC had two units on their shelves that we transfused when we got them, but they had to call all around the country trying to find antigen negative units for her so we were not able to keep up with the Dr's demands. The final antibody was an anti-K that we think probably came from a unit we gave early in this catastrophe.

We refered this case to our Risk Manager and that is the last I heard about it. We haven't heard much from him lately, but I don't want to get my hopes up.

My favorite diagnosis: Tests ordered were KOH, Wet Prep, Culture and the diagnosis was "Dog Bite". After we stopped laughing I said to a coworker that I wanted to see that dog! Turns out it was ordered on the wrong patient and all the specimens were labelled incorrectly, but we didn't know anything about this part for two days. The ward clerk in the ED just crossed out the patient demographics on the results print outs and placed them on the "correct" patient's chart. Who cares that the computer has the results and charges under a different patient, right? My worst case Blood Bank scenario: Patient comes in with 2 known antibodies 13 days after several previous transfusions and goes to surgery with no type and screen specimen. Patient doesn't do well in surgery and Dr requests uncrossmatched blood STAT. We inform him that his patient has multiple antibodies and we don't know if the blood is compatible or not. He says patient is bleeding and needs blood and he will sign the consent for uncrossmatched blood. While she is getting the uncrossmatched blood, we work the patient up and find a total of 4 antibodies in the current specimen. The Dr insists that she is still bleeding the next day and needs uncrossmatched blood until we find compatible blood, and if we were competent in the lab it wouldn't be taking so long to get her blood (REALLY!) Long story shorter: patient ended up with a total of 5 antibodies, received 8 units of uncrossedmatched blood that wer each incompatible for atleast one antibody, developed a total bilirubin of 62 (yes, SIXTY-TWO) before she died 19 days later. Her doctor still thinks WE are incompetent. Even scarier, a similar scenario occurred with the same Dr. two months later with another patient. Obviously, he did nothing wrong!

Can this be done from Meditech without the Digi-Trax printer? Our LIS person says they can, but I am having trouble seeing how to print these for expiration date and time.

Hello, I manage a medium sized transfusion only hospital blood bank that aliquots and pools, but does not collect units. I have purchased unit numbers and other labels for ISBT implementation, but wonder what others are doing about outdates when they process units. It would be impossible to purchase expiration date AND time stickers for the limited processing we perform. Thanks

So far, we are in the minority on this one, but we have a keep ahead order that nursing puts in the computer. Then Blood Bank orders as needed, and so far, none of our inspecting agencies have had a problem with it.

We purchased a Sorvall CW2+ 2 years ago and had all the above mentioned problems PLUS the saline detector did not alarm consistently when the saline was out. We called sorvall and after hassling them for 10 months, they finally replaced it with a new one. We had all the same problems, and none of our techs would use it. It is now in the storeroom and we resurected an old Sorvall from 2002 to replace it. We have a Helmer cellwasher in the budget for this coming year.