jnadeau

I didn't realize he passed away either!  Had called him about the MTS tips being unavailable suddenly and spoke to his wife - she didn't sound good.   Now I know why.  Thanks for the bio-rad info KBBB 

If the original type is for "potential" transfusion purpose then it is confirmed and the history of that type has been validated. It can be added to the paranoid reducing comfort level in assuming  the current sample is from the same patient.  If, on the other hand, the original sample was ABO/Rh type for some other reason and obviously not confirmed with a 2nd type then your level of paranoid reducing comfort will not be there when the patient returns for "potential" transfusions purpose. 
I have never been a proponent of the required 2nd confirmation ABO/Rh type.  I would like to say it was for the same reasons Neil Blumberg listed above but back when I was living in the blood banking world we did not have the data he is noting.  I just could not really see the cost/benefit ratio being in anyone's favor.

The absence of a second sample leading to transfusing group O to everyone without a second sample is an example of why this practice is likely doing more harm than good in my view. Group O red cells are acceptable for all in an emergency, but they are potentially harmful to non-O recipients due to the presence of 20-30 ml, give or take, of incompatible plasma for A, B and AB patients.
There are case reports of severe hemolytic reactions in this setting.  Low level hemolysis that is not clinically evidence is present in some recipients and is associated with thrombosis, infection and organ injury in animal models. In experiments of nature such as sickle cell anemia/paroxysmal nocturnal hemoglinuria below visually apparent levels of free hemoglobin cause severe complications. 
 
Thus, contrary to long accepted practice, Group O is NOT universal  donor,  except in emergencies when the recipient's type is not known,  or the patient's own ABO type red cells are unavailable and there is life threatening bleeding or anemia. 
The routine use of group O red cells for everyone in routine transfusion is an unfortunate practice that has arisen due to convenience and erroneous assumptions of equivalent safety.  Not a good practice for patient safety.

We have A LOT of outpatients.  Using our Outpatient Dialysis patients as an example - If we do not have a second type on them, we will give O units and do an ISXM on their first presentation.  Upon subsequent presentation for transfusion, another sample would be received at which time we will do a second ABO/Rh and barring any discrepancies - will then EXM units provided the screen is negative.

The problem with retesting the same sample is that you don't have a second sample drawn with a different venipuncture to confirm the patient's ABO and can potentially issue ABO incompatible blood no matter how the compatibility testing is performed.

Agree that if not for transfusion purposes, ABO types do not need repeating.  We don't do confirmations for potassiums or troponins either.

OMG - we evidently have a new generation of inspectors.  As Mabel said - OSHA regs.  The real pain is having to respond with a corrective action of teaching them.
 

Under OSHA, tested donor blood is not considered biohazardous.  For heaven's sake, we infuse it into patients!  It would take me some time to find the regulation, but it is in the OSHA regs.

I have heard that it is unseemly to walk through the halls of the hospital carrying a biohazard bag for all to see.   We actually transported all of our blood via pneumatic tube system so this wasn't an issue for us.

 

Some of you more "experienced" people will remember the little saws that we used to score the microhematocrit tubes so we could break off the part with the immature red cells for antigen typing someone who had been recently transfused.  What the heck were those saws meant for originally?  I feel like they came with something else in the lab.  Were they for general chemistry glass tubing?  Also, what tool works well now for scoring the plastic-coated glass microhematocrit tubes since those little saws aren't available?  I found a few centimeters of staples (ready to be put in a stapler) could work.  Hack saw blade?

We used a "Machinist File" to cut glass crit tubes back in the day for baby Bilis.  You can get them for less than $10 at Grangier or other suppliers.

It's remotely possible that Ortho use different diluents for different cells. I remember a rumor that "fresh" cells are suspended in one kind of diluent, but frozen-thawed cells are in a similar diluent with a couple of extra chemicals to compensate for the freeze-thaw process. I think that frozen-thawed (deglycerolized) cells are sometimes used in emergencies when the scheduled donor(s) don't appear.

We have had enough "gelbodies, I really like this term", that I take Immucor screening cells, wash them with MTS diluent and them dilute them to 0.8%. Most of our "weird" ones are negative with these screening cells. Our only other option is to go to tubes and I'm afraid that any negative reactions are due to using a weaker screening technology.
We run daily QC on these Immucor gel diluted cells. Does anyone see a problem with this?
Antrita

NOBODY has EVER performed either an Indirect Coombs Test (ICT) (or, still worse, an Indirect Coombes Test), or a Direct Coombs Test (DCT) (or, still worse, a Direct Coombes Test).  There is most certainly NOT either an Indirect or Direct AHG Test.  AHG is a reagent used in both the IAT and the DAT.
The correct terminology for the former test is the Indirect Antiglobulin Test (IAT) and for the latter test is the Direct Antiglobulin Test (DAT).  It is true that Coombs was the primary author on three papers describing the test1-3, but Mourant and Race were his co-authors on these papers, and they are often forgotten.
Indeed, Coombs himself did not like the test being referred to as the Indirect Coombs Test and the Direct Coombs Test4, particularly as the principle of the test had been described in two papers published in the early 1900s,5, 6.
 
1.  Coombs RRA, Mourant AE, Race RR.  Detection of weak and ‘incomplete’ Rh agglutinins: A New Test.  Lancet 1945, 246, 15-16.  DOI: 10.1016/S0140-6736(45)90806-3.
2.  Coombs RRA, Mourant AE, Race RR.  A new test for the detection of weak and “incomplete” Rh agglutinins.  British Journal of Experimental Pathology 1945; 26(4): 255-266.
3.  Coombs RRA, Mourant AE, Race RR.  In vivo isosensitization of red cells in babies with haemolytic disease.  Lancet 1946; 247: 264-266.  DOI: 10.1016/S0140-6736(46)91925-3.
 4.  Coombs RRA.  Historical note: past, present and future of the antiglobulin test.  Vox Sang 1998; 74: 67-73.  DOI: 10.1046/j.1423-0410.1998.7420067.x.
5.  Moreschi C.  Neue tatsachen über die blutkörperchenagglutination.  Zbl Bakt 1908; 46: 49-51.
 6.  Friedemann U.  Weitere untersuchungen über den mechanismus der anaphylaxie.  Z Immunitätsforsch Exp Ther 1 Originale 1909; 2: 591-641 (cited in reference 4).

I don't think the AABB comments are evidence based.  Washing with 37 degree saline is extremely unlikely to cause false negatives with clinically significant antibodies,  and I'm unaware of any evidence that this is so.  Any such antibody would be very low affinity to be washed away by saline at any temperature, and unlikely to have in vivo/clinical significance. 
As argued persuasively above by Malcolm Needs, anything that doesn't react at 30 degrees or above in typical serologic testing isn't going to cause clinical problems.  Patients are neither at 30 degrees nor centrifuged :).  Our serologic techniques are overly sensitive,  in general,  for clinically insignificant agglutinins. 
No need for cold panels ever, with rare exception, and more for intellectual curiosity than clinical decision making.  Perhaps a mini-cold screen someetimes just to confirm you are indeed detecting a weak cold agglutinin in 37 degree testing, which disappears with prewarm technique. 
Like Malcolm, I've never seen a patient with an hemolytic reaction due to an antibody that disappears with prewarming, in close to 50 years of clinical practice.  I know there are in vitro examples of clinically significant antibodies that weaken or disappear with prewarm, but I've never seen any clinical consequences.

We have been using pre-warming in the UK since before I started in Blood Transfusion (circa 1973) and we have never had a clinically significant transfusion reaction caused by warming away an antibody in all that time.
Yes, there have been occasions when, for example, an anti-S has disappeared by pre-warming, but, if you look in most text books, and all reliable text books, anti-S is only rarely clinically significant - and certainly none of those that we have "warmed away" have caused any transfusion reactions at all.
There was one case of an anti-Vel causing a fatal transfusion reaction, BUT, that was not missed through pre-warming; that was missed because EDTA plasma was used, and the anti-Vel could only be detected in serum (confirmed by the IBGRL), and so I think that the worries about pre-warming are vastly over estimated.
It is vital to keep up with competency for this technique, as with any other technique, but probably more so with this technique.

Yes!

Immucor does that.  They underline anything that has changed and use a closed triangle for anything deleted.  I've attached a copy of one from 2010.  What bugs me we get a new insert in 2016, and it was changed in 2013!  Where has it been all this time??changes.pdf

In emergencies, we always accept verbal orders for transfusion.  These should be followed up by a request documented in our electronic medical record, but that's after the fact.  If you have a paper system, then the followup order is documented that way.  There is a regulatory/accreditation requirement, which I consider bureaucratic, obstructive and useless,  that these emergency requests require a signed release from the ordering practitioner, if the transfusion is not fully tested for the recipient.  

We call them "Alerts" - new hemolytic antibody identified during pregnancy, pos DAT on baby, transfusion error or serious trx, no compatible units for a specific patient or delay of product.  It's called and documented in the computer.

Just for the record, if the blood is leukoreduced, CMV testing is redundant and adds no benefit.  One less thing to complicate life. We haven't used CMV seronegative blood for any patient in 20 years and have yet to have a case of CMV associated with transfusion after >2,000 stem cell transplants and greater than 1,000 transfused premature newborns. Passive reporting, obviously, but this experience is supported by a fair amount of randomized trial and observational data. We also use recently (as in within a few days) irradiated washed red cells <21 days in storage for our newborn intensive care unit.  There is no evidence that red cells any shorter in storage provide any clinical benefit. Indeed, shorter storage red cells are associated with increased nosocomial infection in randomized trials.

We have no critical values in the Blood Bank and we have a cancer center that sees thousands of patients per month.
And it is my recommendation that critical values be restricted to truly life threatening conditions that require treatment within minutes to hours (e.g., very high or low potassium).  I would most definitely NOT have critical values for things like creatinine/BUN, liver function tests, MCV, white count, etc.  Provides no clinically actionable information acutely, and wastes a lot of time in the lab and amongst practitioners.

It sounds to me like you are doing everything that you should do, without either over-shaking the tube, or over-reading the contents.

I am extremely glad that you are not using a microscope, as, if you did, you would almost certainly see the odd couple of red cells "kissing each other", even if they have been incubated in isotonic saline.

The other thing is (and I speak with some 43 years of working in blood group serology) if the reactions in the tube are THAT weak, the chances of any atypical alloantibody that you might miss being clinically significant are absolutely minute.

If you are still worried, however, get a more experienced worker to read your tests as well, until you feel confident.  That is how I learned when I started.
I wish you the best of luck in your future career.

I've been a BB'er for 35 years (at the same hospital)  my very first manager (who was a good,  seasoned BB'er) used to tell us........., "if you have to hunt for it - it's not there".
As you become more adept at reading tube reactions - your eyes will not fail you!  Trust your gut.
As for your technique - it all sounds good!  Practice with a few techniques to find the one that works best for you
I "tilt and giggle", button up, The tilt helps with seeing Mixed Field - which we tend to see a lot here - It also helps with seeing "how" cells are falling off the button - are they chipping off or are they "swirling" off.....or is there a little of both?  (For some reason I always think of the "tail" of an old RPR test .....which probably dates me, LOL!)

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