rravkin@aol.com

Dear Marina, I live your question every day. At my primary job there is no such criteria in place for performing manual differential and slide reviews in any given period. We perform as needed and/or required. At my pool position we will perform a manual differential and /or slide review once per week as long as certain criteria are met. I believe that the difference in practices here may reside in the instrumention used. My primary is still using the Beckman/Coulter LH ( they are looking to upgrade soon) and my pool position uses the ADVIA. The ADVIA is capable of being utilized in the clinical and research setting where as the LH is used mostly in the clinical setting. The ADVIA measures more parameters but requires more preset maintenance. I am not trying to sell you on either instrument, but from practice I think that the LH is the better of the two in the clinical setting. I hope this helps.

Autumn, In the pre-delivery specimen the Anti-Jka was at such a low concentration that it was not detectable through your testing procedure. Does that mean that there was not a significant enough concentration that crossed the placenta into the fetus? One of the previous posters described how the concentration of the antibody would be hire in the fetus. This stands to reason given that this is where the sensitizing antigen resides. So it is better to error on the side of caution and transfuse antigen negative PC's for this neonate especially in the absence of a direct specimen.

Autumn, Bill's response is the standard thinking when working with inpatients however in this case the pre-delivery specimen would be the specimen that the fetus experienced prior to delivery and when performing the IgG xm, would promote a greater reactivity, if any, then the post specimen. If any products are needed for mom then a new specimen would be in order.

I always make the slide for differential using the cytospin. If the WCB content is elevated then a diluted aliquot (with saline) is used. The shrinking effect that you have metioned when making a push smear has to do with the concentration of cells and the viscosity of the body fluid. If the fluid is of low viscosity and elevated cell concentration you may see normal sized cells on a push smear but increase the viscosity with the same cell concentration and the cells will appear smaller. The cytospin has the advantage of using centrifugal force to push the cells onto the slide as opposed to speading them as is the case of the smear. Also, and perhaps most important, is that when making a cytospin use a drop or two of albumen (22%) prior to adding your specimen and this will allow for a slower and steady migration of the cells to the slide during centrifugation. The use of albumen is a good practice with low viscosity (thin) body fluids. The higher viscosity fluids like Synovial does not require albumen for a neat low cell concentration specimen. However, when employing hyaluronidase along with saline for dilution the initial viscosity of the neat specimen may be lowered enough where use of albumen may be necessary. It's late at night and I hope that I am making sense and I hope this helps.

Dotahill, I agree with Bill except with respect to the time saving. Manual Gel testing really does not save alot of time as compared to the tube method. There is a 15min incubation followed by a 10min centrifugation, a very similar time frame for tube method. Gel has the advantage of less hands on work which would free up time for other work once the incubation is started. The columbs are easy to read however, as has been stated, the system is much more sensitive and therefore tube method is often used to resolve any questionable results. Manual Gel is the stepping stone to automation which offers greater consistancy in testing, and is walk-away capable, and any time saving over tube method would occur through greater volume testing. Good luck with you decissions and let us know how things go.

Brenda, When one tapes a patient name to the outside of an "outpatient cooler" is there not a concern for HIPPA violation or patient discression?

I think that in the abscence of an automated distributor a Blood Bank tech is your better choice given that you have a special needs population at your facility and the issue piont is the last chance for the Blood Bank to catch any errors prior to issue.

Robert, I don't see in your post that ABO/Rh typing is counted as work per FTE. Your data would seem more complete if it were counted given that the ABO/Rh type is a routine part of a typical work-up. How is an ABO/Rh type discrepency resolve taken into account; not to mention positive ABSC's and other non-routine testing?

Blessed, You may want to check with State Agency; I remember that some states do give recommendations on BB work load per tech.

This is a very interesting subject we are talking about here. But I would ask the posters here why is it that the unit of PC's can not be returned to BB inventory if it reaches 10C or if it is out for more than 30 minutes and yet the initiation of the very same unit can be within 4 hours of issue; depending on your practice? What is the logic behind the FDA rules and regs. governing this practice? I think that the FDA, as well as other governing bodies of BB practice, have the goal of patient safety at the for-front of all their rules and regulations. So why is a unit of PC's safe to transfuse within 4 hours of issue and yet not safe to return to BB inventory in 30 minutes or less time if abiding by the 10C temp rule?? Does anyone have any actual articles that they can reference here?

I have the same understanding and practice as Steven Jeff; the unit must be returned to the Blood Bank within 30 minutes once out of temp controlled storage; I also understand and practice that the unit must be transfused within 4 hours once the transfusion is started; therefore the transfusion should be started within 30 minutes of issue or returned to the BB within that 30 minute time frame given that this is the time limit where the unit can be outside of temp controlled storage where the transfusion has not yet started. Its a strange dicotomy in that the reason for the 30 minute time frame is to deter bacterial growth in the PC prior to transfusion and yet if the transfusion is started in a maximum time of 30 minutes the very same unit now being transfused can hang at room temperature for a maximum time of 4 hours. A new generation of bacteria grows every 20 minutes. So how can it be that a PC out of temp controlled storage and not transfused for 35 minutes is less safe than a PC, where the transfusion has started within 30 minutes, at, say, 219 minutes at room temperature?? There is the 64 million dollar question? I have also seen the similar situations that Deny has mentioned where the patient may spike a temp prior to transfusion but unfortunately after issue of PC. Also the IV sites can become coagulated again, unfortunately, after the PC is issued.

Eoin, This sounds like a fantastic system; can you tell more of the pros and cons of it's use?

Rita, We use a Request for Blood Product form which has patient info (matching that of the patient bracelet); the patient ABO/Rh type, the type and number of products requested at this pick-up, a place for the transport personel to sign that they have recieved the product, and a place for the BB to record the unit number of the unit issued. And we keep this for our records.

dmpollock, I have a co-worker who performs screening and crossmatch at cold temps. as well as our usual temps in order to avoid the very case you present here. I believe that the reaction volumes are incubated at 4C but I don't recall for how long.

John, This sensitizing event does not just apply to detection of anti D but also any allogeneic antibody; especial those most prominent during gestation. Therefore, the post specimen would be screened and worked up if positive, with potential future titering.

Colin, Thank you for posting this response and the two articles; especially the second, very comprehesive, article. This topic as a whole is very important as it is but a part of the overall topic of Hospital Born Infections; including outpatient services. Having studied the sciences and, to some extent, health delivery service, historic and contemporary, I find it an appauling enterprize where the sick will go to be treated and potentially encounter more illness from the very place they are supposed to be getting well. I realize that my statement is somewhat simplistic in describing the much more complex system of healthcare delivery but the organisms causing desease certainly take advantage of every opportunity we offer. Thank you again for your posts.

Free or nominally free healthcare; NOW THERE"S AN IDEA. It's a shame that in the states our politicians seem so tourn over this idea that appears to work well enough in several other countries. Don't take it for granted, free health care is what should be. Congradualtions!

Colin, Thank you for this reply. I look forward to your next post.:)

Anna, By "normal crossmatch" do you mean AHG X-match or IS X-match?

Collin, In the article you present it seems that much of the predictability of contamination of a unit of platelets rely on the initial culturing (when the unit is first established) for bacteria which is not complete by the time the platelet unit is distributed and/or transfused. As such there is still a question of contamination prior to transfusion, especially when the shelf life is extended to 7 days. The article does not seem to address this issue as the initial culture may remain incubated at this time. So, is it possible that the initial concentration of bacteria potentially present in a unit of platelets will fall below the initial culture sensitivity capability for greater than seven days and yet increase to clinically significant levels in the unit itself on the seventh day where bacterial testing is or is not performed? I thought that recommendations stated that testing for bacterial contamination prior to transfusion was the primary focus. If we test for bacteria using culturing methods their detection capability inherently can not always, or reliably, identify clinically significant levels prior to transfusion. Furthermore I would ask if the platelet unit is capable of becoming contaminated during it's shelf-life? If it can then the initial culturing is again potentially incapable of preventing the transfusion of contaminated platelets. In closing there still seems to be a need for a testing system that will detect clinically significant concentrations of bacteria immediately prior to transfusion. I thank you in advance for any consideration and response. I cann't wait for the day when we can use a handheld scanning device, like on Star Treck, to detect clinically significant levels of bacteria in units of platelets.:)

Dr Pepper, I agree; there are variations on the basic ranking system and uniformity is a huge benefit when sharing results with another facility. Thank you.

BSIPHERD, Why are there only a limitted number of techs trained in a procedure that your facility offers 24/7 for traumas? It would make sense to train all of your BB staff to perform this procedure. The primary problem with K/B staining is the lack of use of the procedure; when it is used more readily it is not that difficult. I have turned around K/B staining results within an hour to two hours; and I thought two hours was too long at times. The K/B stain procedure is not difficult you just have to practice it like any manual procedure.

The purpose of the recommendations for calling reaction strengths in the AABB Technical Manual and the reaction chart that comes with the Gel system is uniform calling of reactions. So on this piont I would disagree with Dr Pepper's statement that " each facility should come up with their own policies where you define your own criteria for grading reactions." Can any other posters explain further the benefit of uniform reaction grading; for me it is intuitively correct but I do not recall the reasoning.

Misread.

At a hospital that I worked there was an electrical outage do to a lightning strike of a transformer across the street from the hospital. Only emergency lighting was working in the lab located in the basement of the hospital and therefore the hallways outside the lab were completely dark as this incident occured on 3rd shift. Location was northern suberb of Philadelphia. We came to find that our Helmer blood bank refrigerators where not hooked up to emergency power. As time wore on we became concerned that all of our inventory would expire as a result of being out of temp. Myself and a co-worker went to other parts of the hospital, which was also on emergency lighting, to try to round up ice for transport boxes stacked in the blood bank from previous deliveries. We ended up in the hospital kitchen with flashlights in hand retreiving ice from freezers and ice machines. The Helmers, as we came to find, are designed to hold their temps with doors remaining closed for 2 hours without power. Not bad. The conclusion was that we watched the Helmer temps closely and luckily the power was returned in about an hour and a half. The boxes that we had collected ice in would only have been able to hold about a third of our inventory, O Pos and O Neg PC's. I did not see any immediate changes in the desaster policy after this incident. Life resumed as normal, but there were some very tense moments. As far as the thought of anyone needing blood during this time we just maintained a state of readiness and were prepared to do all necessary work to produce compatible units; flashlights in hand.