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Posts posted by jcdayaz
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WOW! And the PEG adsorption discussion goes on ..... When are these antibodies going to start reading the rule books? haha!
I had a patient just last week with a fairly impressively strong warm auto (3-4+)--I did 3 successive PEG adsorptions and couldn't get rid of it. The testing had started on the previous 2nd shift, continued on the third shift and then was "gifted" to me the next morning. After I spent close to 7 hours on it, I finally gave up and sent it to our reference lab. They start with PEG adsorptions also. They had to convert to the WARM adsorption procedure. Does anyone have any information on when/why the PEG adsorption doesn't work?
Thanks in advance.
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I believe that whoever wrote the 'Store at 1-6, Transport at 1-10' rule was a bit narrow sighted.
Obvious storage is in our refrigerators, but what about the boxes we 'store' the blood in while they are waiting (sometimes for hours!) to be loaded onto a truck? Are they 'in storage' or 'in transport'? When they are IN the truck,we clearly see them as 'in transport'. So, I guess the criteria is based on is really 'is it in a moving state?'. Given that, if the cooler is sitting on the ground, it must remain between 1-6oC. If it is being carried somewhere, it can go up to 10oC. (Ummm, what temp check stickers are we using, 1-6 or 1-10 for these?)
Are we all nuts or what!?
Whatever ... the rule should be rewritten for clarity's sake: e.g. RBC's must be maintained at 1-6oC. However, if allowed to warm up to 10oC for longer than X minutes (hours?), then the outdate must be amended to ____ (24hrs?). If allowed to warm up greater than 10oC, it must be discarded. (Interesting that the current rule states we can't reissue it ... why doesn't it state we must discard it? Do YOU store such units in quarantine until they outdate? We don't either.) This is how it is stated for bones ... it's very clear what to do when.
So, if there is anyone out there who has any control over writing the FDA regulations, can you bring this up at your next meeting please?
AMEN! I think to be a Bood Banker you have to be nuts!
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Brenda,
I concur completely with you. We use HemoTemp indicators on every unit sent out to OR (typically) in a cooler. The temperature of the units upon return--if they are returned--is documented in our computer. Our coolers are validated for 6 hours safe storage time based on our in-house validations. We will call the OR @ the 4-5 hour time frame post-issue and ask for the return of the cooler to the BB to get fresh cooling packs, frozen packs, etc. We have a dry-erase board upon which we write when whatever cooler was issued so we can all monitor the length of time it has been out.
BTW-I've not heard anything either about a change to the 30-minute rule. If you find anyting out please let me know.
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We also use Meditech and can result as least incompatible (L).
Currently I have 2 patients with WAIHA. The first is e negative (surprise!) but has an auto-E as confirmed by our reference lab. Which do we choose? The gel crossmatches are all 3+; the LISS tube crossmatches are 4+ with Rh positive and 2-3+ with Rh negative. The docs are holding at the moment since she has a 7 gm hgb. I haven't yet phenotyped our stock.
The second patient is an outpatient needing hip replacement (second time). Our reference lab phenotyped him for us in January. He is E, c, Jka, Fyb and s negative. I know the statistics for finding phenotypically matched blood, but I don't see any other choice!
What would you do?
Good luck finding an E,e negative unit to transfuse in situation #1 you describe here. If it were me and the patient absolutely HAD to be transfused right now, which it sounds like she/he doesn't, I would go with E negative blood. It sounds like the e is a possibility, but not present yet. Yes, it's rolling the dice, so to speak, but what options do you have? In this situation we would call the attending physician and "Strongly Urge" the use of steroids to try to get the Auto antibody under control. Obviously we can't prescribe medicines, but we can "Suggest" their use when appropriate. The Doc's are normally very receptive to our "Suggestions". We have a patient that comes in from time to time that has the exact same scenerio. Sometimes when her Auto is strong enough, we just simply tell the Doctor there is no compatible blood and he/she will have to sign an Emergency release form for incompatible blood. Then it has to be OK'd by our Medical Director who has to sign the emergency release form also. He will call the attending physician personally prior to signing the form to ascertain true medical need. It's a pain, but sometimes what choice do you have? We have done this probably only twice in my years at my current facility. Odd how the urgent need for blood becomes a little less urgent when a MD has to put his/her signiture on a legal document.
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You are not lying at all here Liz. Not even considering the "human error" side of things ie. phlebotomist/nurse collecting the wrong patient, mislabel, blah blah. I could continue on and on as I'm sure we all could. I have seen a couple presentations of Bone Marrow Transplant recipients that received a transplant of a different blood type. It takes a bit, I don't remember now how long, but the recipient's blood type will change to the donor's type.
I'm guessing that's not what you were referring to--but I thought it was worth mentioning because the science behind having your blood type physiologically changed is fascinating to me!
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The PEG I referred to in my previous post is not a regular PEG panel using neat serum. It is a PEG adsorption procedure. You can get the same (if not better) adsorbed plasma/serum to then use for your regular antibody id. I don't see a way around the adsorption step, but I do know the PEG adsorption can save hours!
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Sorry to be the bearer of bad news, but in my experience you will maintain your headache if you pursue the WARM procedure. The PEG procedure is much easier, quicker, etc etc. In my humble opinion, the step in which you use the PEG procedure is after a panel has been performed to check for "real" specificity and a positive auto-antibody has been confirmed. Then you can use the PEG process to show any underlying alloantibodies.
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We have an option in our computer system to enter "Least Incompatible" in our crossmatch result section. We then contact the physician and require a new order to be written and sent to us by him/her for "Least Incompatible Blood" to be transfused. This has to be ok'd by our Blood Bank Medical Director prior to issuing any blood for the patient.
That's how we do it. Good luck!
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I will not deny that Harry is clever but I defy anyone to be anywhere near me when I am wealding a paint brush and to be called intelligent!!!!!!!!!
I still favour cutting the offending bit off - at the neck!!!!!!!!!!!
:rofl::rofl:When you're done cutting Harry's "offending bit" off, I have a couple of my own clever ones for you to take care of....
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Um...
My lab strictly uses 3 homos... and 2 heteros can replace one **** if absolutely necessary...
What's your take on my lab's methods? =S
Well, hmm. I think the term "strictly" just might not apply here. Are you saying if you have something like an Anti-k your policy dictates that you have to find 3 homozygous cells to prove it? We keep 6 months of expired panels to use for select cell purposes. I'm not sure we would be able to find 3 homozygous k cells in our six month inventory.
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Kudos to you KKidd!
I agree, except for the "2 grade increase" and the "been a long time since the patient has been at our facility" statements. I think "been a long time" is not objective enough. What one Technologist thinks is a long time might be vastly different than another Technologist thinks.
I have seen a couple of cases of Fya and Jka that presented themselves with only a slight increase in screen reaction strength. Certainly not a 2 grade increase.
(Totally not applicable to your post, but...)In the world of blood banking I have always been taught if I see hoof-prints I am to look for horses first. If a horse doesn't match the print then I look for zebras. It has served me well in my career. I hope it can help someone else!
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Wow, this Thread is still alive! I have not been able to login for some reason but finally made it.
I have taught enough residents and fellows in my career to know how little of Lab training they get in Medical School; and then the limited bench level training they get in the Transfusion Service. But it just seems like this very basic principle should be explained better in Medical School.
Brenda Hutson, CLS(ASCP)SBB
YOU HIT THE NAIL ON THE HEAD WITH THIS STATEMENT!!
It seems, unfortunately like a large percentage of physicians graduated from Deny's "God 101 class"(see her previous post). Unfortunately often times they don't know and/or recognize that they don't KNOW the appropriate treatment for their patient--even after we tell them(well, strongly suggest) the treatment that needs to be used.Funny thing....When my Blood Banker friends come to my house we always eventually end up discussing blood bank issues. Even my own husband doesn't get it!!!! Not surprising I know, but he will debate and argue and etc until we just shake our heads and know that there is no hope.
Oh my, the patience it takes to be a blood banker and married to a physician is UNBELIEVABLE
CALGON, TAKE ME AWAY!!!!!
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Personally I prefer dealing with the physicians who failed the "God 101 class". This group is at least more apt to listen and then decide ranther than to assume they know everything. I think I am beginning to see a trend of the younger docs listening more to the "specialist" front line workers. Some are actually rather down-to-earth. Hang in there and keep chipping away at the block of arrogance a little at a time. I try really hard to kill them with kindness and refuse to lower myself to the bad attitudes experienced from some quarters.
I LOVE the "God 101 class" statement you made!!! Kudos to you Deny!!!!!
The very unfortunate fact is that it is all too common.
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I know of other institutions that use coolers for blood in Surgery as you do. What problems have you (or anyone else who is reading this) encountered with your system of using coolers?
Has anyone using coolers ever had a problem with the cooler being left in the Surgery suite, then assumed to be for the next patient using the suite? Or maybe the cooler got transported with the wrong patient to ICU or CVU? (I worry about those problems.) Thanks in advance for any comments on your experiences.
I have worked in places that used both methods. In my experience the refrigerator in surgery has proven to be more problematic. There could be many different patients' blood in there at the same time. Who knows if they will grab the right unit for the right patient when they need one. At least with a cooler you issue one patient's blood at a time and it goes directly to the operating room for that patient.
We've never experienced any issues with a cooler being left in surgery and then assumed to be for the next case. We do, on occasion, have to call surgery and tell them we issued a cooler to them at XXX time and it needs to be returned. We tell them there is a 4 hour time limit on blood in a cooler, even though our coolers have been verified up to and exceeding 6 hours. If they still need product in the room with the patient we pack a new cooler with new ice packs and etc and send it back with them. We affix temperature labels (HemoTemps) to each unit. If the unit ever exceeds acceptable storage temperature we know it immediately by checking the label.
We do continue to have infrequently a cooler being sent with the patient to ICU post-op. We simply call ICU and tell them we need the cooler back. They bring it immediately. We've never had a problem with it going to the wrong patient's room.
The cooler works the best for us!
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Hey Malcolm,
I got the right "fallible" this time!:cool:
;) -
Lara123
In our centre we do not do IS but if we perform it; it will be counter check for miss-pipetting for testing or miss-labelling of the unit.
As Lara123 stated very well, even with that IS crossmatch there is the potential for mistakes made by your Technologists.
We are all human and are fallible.
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In my humble opinion, there will always be certain cases that don't follow the rules(so to speak).
We do electronic crossmatches on any patient needing blood that does not have any antibody "issues". It works GREAT for us!
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Yep, when I was working in the hospital environment, I sent an anti-P1 to the Refrence Labratory for identification. Embarrassed or what!!!!!!!!!!:redface::redface:
HAHA!
Yes, very embarrassing:redface: Sounds like the time early on in my career that I sent what turned out to be an Anti-M to a reference lab.:redface: -
Malcolm this site would be poorer without your posts and one thing about blood bankers is we all seem to have quite strong views and I am sure we can all verge on the self-opinionated at times, but good thing about a reasoned debate is we can also all still learn something and at times have our views changed by a well formed line of thought. Anyway please keep posting.
Very well said Colin! And VERY true!!! I think what you posted is a sign of a good Blood Banker. Most of us seem to be stubborn and strong-willed, but hopefully still receptive enough to learn from new information/experiences. Or,in my case, be reminded of what you used to know before your two young children drained the memory from your memory bank!
:cries:This site would indeed miss Malcolm. His posts are always so informative and educational!
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Now Malcolm, even if we thought that most of us are polite enough not to say it out loud!
Funny John.
:D Nice one. I hope I don't fit into the category Malcolm is referring to!! -
True, but it is tragic/disgusting that:
a) they don't know and
they don't care that they don't know.Very true Malcolm! In my humble opinion a good nurse/doctor is one who will admit he/she is not very "schooled" in Transfusion Medicine issues, ask for help from us, and then actually take it!
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Great one phil!!!!!
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I've heard (and occasionally said) Blood Blank quite a few times.
I'm guilty also!
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How about answering the Blood Bank phone after being paged by the central lab to take a call "Hi, this is Jane in the......um(long pause), um(long pause)...How can I help you?":redface:
How sad is it that your brain can get so fried by some ridiculous antibody you've worked on the entire day that you can't even remember which department you work in????
:cries:
:rofl:
It seems, unfortunately like a large percentage of physicians graduated from Deny's "God 101 class"(see her previous post).
Unfortunately often times they don't know and/or recognize that they don't KNOW the appropriate treatment for their patient--even after we tell them(well, strongly suggest) the treatment that needs to be used.
. This group is at least more apt to listen and then decide ranther than to assume they know everything. I think I am beginning to see a trend of the younger docs listening more to the "specialist" front line workers. Some are actually rather down-to-earth. Hang in there and keep chipping away at the block of arrogance a little at a time. I try really hard to kill them with kindness and refuse to lower myself to the bad attitudes experienced from some quarters.
;)
:redface:
they don't care that they don't know.
what type bag do you issue blood products in?
in Transfusion Services
Posted
The coolers need/have to be tested, verified and DOCUMENTED that blood is maintained at appropriate temperatures for the amount of time that your blood bank allows the coolers to be issued. Each unit issued in a cooler must have a temperature indicator on it. When you say "ice packs" I hope the units are not being placed directly on the ice. We have an inner plastic type square bucket in our coolers and place one frozen pack and two ice packs on either side of the bucket. The coolers have been calibrated to be acceptable for 6 hours. We start calling and telling the ER, OR and ICU after 4 hours to return the coolers. It gives us a little time to be sure we get the cooler back in time. We will not send coolers to regular floors except in extreme circumstances like a plasma exchange or something like that.