CM2

Mabel- We require this extra draw to confirm ABO (and by extrapolation, patient identity) only once on their first ever visit with us - people who have no history on file. Any time in the future we deal with them again, either current stay or future admits, we dont require any additional tubes be drawn (besides whatever T&S is required due to specimen outdating I mean). So I think you can argue its a self-limiting blood loss and the return in patient safety far outweighs the cost. We perform the front and back type in tube. Since nearly all of our initial T&S samples are run in gel its also a crosscheck for type discrepancies due to quirks of methodology.

If by "pretransfusion" you mean the pre-admission testing done before a patients surgery admit date to ensure safe blood is available on the date of their procedure, then yes, we will need a 2nd sample drawn. It can be drawn by a second phlebotomist in that outpatient draw location the same day as the first sample (rare, phlebotomists dont have access to our blood bank system to check), or collected on the date of their admission - either is acceptable as long as samples are properly labeled for blood bank. But if you mean samples drawn in the doctors office just as an fyi with no hospital admission/transfusion anticipated, then no. We do electronic crossmatch and I believe 2 samples are a requirement to do so. Its a great practice in general anyway imho - you dont have to work in blood bank long before you see all manner of swapped labeling, misdraws and general wierdness. You just pray it doesnt involve your name Robert Wood Johnson New Brunswick NJ

Hrm.. I dont think our policy explicitly states that uncut armbands must be refused. Perhaps I should leave my answer at that =)

Itechlin: They are given a preadmission armband at time of PAT sample draw which they have to keep (we dont require them to wear it for those 30 days =P). They return with this armband and give it to us, theoretically proving they are the same person who had the sample drawn. They get a "real" armband placed at time of admission for their surgery which they are required to wear the duration of their inpatient stay.

We draw samples up to 30 days before surgery. If screen is positive or historical antibody, 3 day rule from date of sample draw. If screen is negative, patient must return on date of their procedure with the preadmission armband issued at blood draw and be asked the pregnancy/transfusion in 3 months questions. armband is stapled to form, patient signs it, we get it, and change outdate to 3 days from that return date (not to exceed the initial 30 days assigned).

Agree with likewine. We depend on this quirk in RH neg massive bleeder scenarios where our policy is to switch to RH pos during the bleedout event, switching back to Rh neg once the crisis is over. If this wasnt the case, Id think we'd have a huge issue with patients developing anti-D and delayed hemolysis a few weeks after, yet it doesnt seem to happen. Id also mention ppl who get 10 units rbcs tend to start getting plasma and platelets as well at that stage, so the plasma youre drawing to retest is that much less likely to reflect the patients actual immune status.

Our policy is to perform a repeat ABO on a 2nd tube from a separate venipuncture if no historical record exists. The idea is to have a second check of patient ID and specimen labeling starting from scratch so identification errors will be caught - 2 tubes drawn at the same time (eg sharing the heme tube drawn from the ER rainbow, or antsy anesthesiologist drawing both in OR at once) would not be acceptable. We moved to this requirement to decrease wrong blood in tube events as well as to be compliant with the electronic crossmatch regs. We do not use any of the secondary blood bank armband systems/barcode scanners at bedside.

We have been using the Origen Cryostore 250 bags since sept 2010 (so about 20 cases used so far) after Baxter threw all its CT customers under the bus. We havent had any problems of any kind with them yet and would recommend them. They also have a cheaper price/case than the Baxters did. The only negative thing I would say about them is I find the opacity of the plastic annoying when you take bags out of storage and try to read the labels in the side pocket during label check. A very minor complaint.

We had to retain our circular charts for our liquid nitrogen freezers because the system we got (Isensix) wires directly into the freezer controller rather than having its own temp probe. Therefore it only senses the equipment is in alarm condition, but not why. We kept the charts for the other equipment as well just for conformity. We could probably do away with the charts for refrigerator and incubator since our sensors are set to do temps about every 30 secs. Batteries arent a problem since they are user-replaceable AA's in the sensors and you get low battery warning when they are going. Had it about 2 years now and have only replaced one set. Just our experience with one system -)

It can take up to 4 months for rbc production to be completely swapped over and isoagglutinin titers to reflect only the new population of cells. Delayed rbc engraftment is most often seen in nonmyeloablative allogeneic transplants. It is possible for someone to be wbc fully engrafted by RFLP/Fish but still have old populations of mature recipient plasma cells circulating making the old ABO antibodies, so wbc chimerism studies are helpful but not the full story. From a practical standpoint L106's suggestion of crossmatch compatible is defensible. At our institution for simplicity and caution we usually just wait until the front type is no longer mixed field (Most patients dont continue to use rbc for longer than a couple months post transplant unless they relapse or under certain anti-viral drugs) and the old back type is no longer showing. Formation of new backtype antibodies (eg A -> can take even longer since the whole immune system is basically being reconstituted so you probably dont want to specify waiting until that occurs. This policy does mean they have convoluted ABO specific needs for a while longer, but its low risk and doctors love low risk =P There is a good article in last month's TRANSFUSION, volume 51, June 2011 called 'how do I approach ABO-incompatible hematopoeitic progenitor cell transplantation?' by jennifer daniel-johnson and joseph schwartz. It is more transplant-side geared rather than from the BB standpoint but its a good overview of the underlying process.

We use the Sebra handhelds model 1090 and model 2600. The 1090 is still working great since 1995, the main unit can be placed on the floor out of the way and you can adjust the current if you seal a variety of tubings (eg transfer pack tubing vs washed cell disposable kits, big tubing thickness difference).

We perform testing on cord blood samples for babies of Rh pos moms. If mom is Rh neg we request a heelstick sample preferentially. One reason for this is that cord bloods often come to us with minimal labeling whereas heelsticks are a little more thorough. Since we are using the testing on the heelstick to dispense rhogam we'd like the extra assurance of correct identity. Cords may also contain Whartons jelly causing false positive reactions if not well washed.

I think you should talk to your radiation department in the hospital and see if they monitor their personnel with radiation sensitive badges. We hang one on the machine continuously and it goes in every 6 months or so along with the people badges to a company that reads them. That way you know the maximum possible exposure your personnel could have. And you dont have to invest in any expensive equipment.

Ah, you are correct, it is NIST traceable which has seemed to satisfy the inspectors for our weights and the thermometer checks. Im not sure who needs the higher standard certificate :-?

For the waterbath and refrig thermometers I use a mercury standard from chemistry department that they pay to have recertified yearly. For the -80 I use Item 15-077-961 from fishersci.com $65 - its an electronic thermometer with probe on the end of a long cable and digital display, this lets me put the probe inside the freezer and read it from outside without opening the door. It comes with a 2 year certificate and has a range of -99 to +199 C. I find the +/- 2C accuracy to be too wide for the midrange temps but its ok for this specific application.

What we do for ours is to buy one thermometer that is actually certified (comes with NIST certificate, has expiration date) and use that one annually in comparisons with all the other thermometers in use. As long as you show annually that the thermometers you are using are equivalent to the one standard NIST within a stated allowed number of degrees, you dont need to reinvest in All NIST certified thermometers every year or worry about getting the certificate for the IR therm- just show its been compared in lab and shown equivalent.. Obviously you must compare thermometers intended for use in the same temperature range - if you try to use one single one to cover -80C to +37C you will probably run into problems at the extreme ends of the scale showing greater deviation. You might check with your other lab departments and see if they've already invested in one you can borrow.

We dont charge for storage of stem cell products. As far as I know there is no CPT code for it. We store products indefinitely until we have either direct knowledge of a patients death or they are listed on the social security death index. So far this has been accepted by financial as a cost of running a transplant program. If one of our financial people was chasing us to set up a way to capture some revenue to pay for the new freezers we keep needing to buy Id love it

Many years ago, training as a new tech in blood bank in the evening (which was just coming up on gel technology), I got given the golden gem of advice - "If you get a weak positive in the gel card just respin it and it will go away". Needless to say this was just one of several symptoms that got this guy permanently banned from working down in blood bank, and eventually from the laboratory entire =P

We sometimes see reactions due to the preservative in the prediluted 0.8% cells. Sketchy positive reaction in the 0.8% initial screen, weak sketchy reactions in the 0.8% commercial panel. But if you take 3% cells (either screen or full panel) and dilute them down to 0.8% with MTS diluent 2 (dil 2+ if making enzyme panel) you get no reaction at all. We will document the results of both the original screen and inhouse diluted screen in our system and then result the screen 'negative with inhouse cells' and make notes to the tech to use prediluted screen cells in the future. This method assumes you run QC Pos and neg with your self prepared diluted cells that works, and that none of the self diluted cells show any positive reactions - if so you must assume real antibody present and do further workup/ruleout.

Well this 5th freezer was actually approved in response to our FACT inspection to satisfy that alternative storage requirement. The inspector did not say it needed to be offsite, only that if any one freezer fails, we have a working backup freezer with the space to contain all the cassettes. So there might be a little play there. The company that sold us our last 3 freezers (Northeast Cryo) does offer rental freezers in case of equipment failure also. Although the logistics of getting a new freezer in, validated, and all the cassettes swapped in a timely way would be challenging its at least something to offer an inspector to say youve thought about the problem.

Our transplant doctors are very reluctant to ever discard cells from any living patient. We currently get to toss only products from deceased people and while we are happy we have so many patients still alive after 15 years...Yeah, storage space is becoming desperate. We have the current problem of a 5th freezer being approved for purchase but not having anywhere to physically put it. Offsite storage gives us worries because of loss of oversight (non stem cell people rarely understand our neuroses over strict storage conditions) and concerns for retrieval delays if those products are ever actually requested for use. For those 2 major reasons we havent done more than a quick glossed over search for offsite vendors which turned up 0 offering this service for a hospital transplant program. Local cord banks might be an option? Our current preferred options are creating a second storage-only room for a couple freezers and tanks still onsite or a whole new larger lab. I can guess which way that discussion will end up. Sorry we havent solved this problem either =)

We dont do DLI's too often. Maybe 1 a year. A good candidate would have received an allo transplant from that same donor already but their bone marrow or peripheral chimerisms show increasingly mixed populations (% donor cells drops), or disease relapse AND they dont have significant problems with GVH yet. A small dose is given to start of around 1 x 10^7 cd3/kg and wait to see if they get good response without causing too much GVH. Good response = an increase in % donor cells without significant GVH complications. If the dr feels more is needed we try ascending doses of 5 x 10 ^7, then 1 x 10^8. PS. Randomly giving cancer patients lymphocytes Would be dangerous (Thou shalt irradiate) if you hadnt already transplanted them with marrow cells from that same donor earlier, thus replacing their immune system =)

A few questions for you: Are you saying the majority of your transplants are haploid transplants (only 50% HLA matching)? And that you create persistent chimeras intentionally where both blood types are co-produced for an extended period? Does your lab perform T cell reduction for the primary purpose of red cell/plasma reducing a graft? I think I must have misunderstood at least some of your points because all 3 of those things would be considered very unusual protocols here in the US =) Standard practice for allo transplants for my institution is to find a preferably related donor who is as fully HLA matched as possible (6/6). For patients with poor outcome translocation leukemias they may rarely consider an unrelated donor 5/6 hoping for increased graft vs tumor activity - but with reluctance since it comes with the price of increased graft vs host. Im guessing you call graft vs host disease "passenger lymphocyte syndrome". The process where the T cells produced by the new graft become reactive to proteins on recipient healthy tissues rather than abnormal cancer clones or normal damaged/sick cells which Should be removed by the body. Here in the US, haploidentical transplants (in laymans terms, HLA matching of 3/6 or less - not matched at all) are only performed with an IND - a research protocol approval only, it is not standard practice. We have only had experience with one T cell depletion we performed on the Baxter Isolex for a haplo transplant. It had good T cell reduction but the patient got terrible GVH anyway and it did not end well. I would guess thats because starting out with a T cell reduced graft is only part of the story, your new graft will eventually produce new T cells on its own which all come with the same chance of becoming reactive to your recipient. One bad sunburn where the T cells come running to check out all the damaged skin and all your work is undone. We would never consider using T cell depletion as a method of reducing rbc/plasma content in a graft since it is such involved manipulation. You will always lose TNC and whats more important - having enough TNC to ultimately engraft or managing short term hemolysis? Our allo transplants are pretty much all fully ablated meaning the existing marrow is wiped out, so once the existing original rbcs die out over their normal life they do not come back. This means hemolysis is transient and generally manageable - its rare our related allos require more than 2-3 units rbcs for support in that lag between wbc engraftment (12 days )and full restoration of hematopoeitic potential. (2 months). Managing infused blood types in that time period we use the same algorithm that shily describes, basically choosing blood/products that will not react with either type. If I would guess if you had a persistent chimera created, trying to plasma pherese out the ABO antibodies would be futile since they are generally high titer and quickly replaced. RBC exchange with O units might buy you some time. Certainly dialysis could become necessary if there was persistent hemolysis from new marrow produced rbcs. Graft vs host prophylaxis generally targets the T cell mediated tissue reactions which are sort of separate to me from rbc hemolysis issues. I dont know anything about how effective off label use of rituximab is for that type of autoimmune anemia. I know they use it in mismatched kidneys but the mechanism of how anti-cd20 could affect rbc hemolysis is a mystery to me. Something to look at for lunchtime I suppose =).

For us the minimum acceptable dose is 2.5 x 10^6/ kg ideal weight for autos. MM patients they collect 5 million to have a second transplant in case of relapse. They always want more however - more like 5 or 6 per transplant if they can get it. Its a bit frustrating at times when the requested amount seems subject to various arbitrary decisions such as having 1 obese patient with complications engraft slowly - therefore all obese patients should get "more" for the next 6 months. Suddenly 10 years of data using ideal weight becomes irrelevant. We have just started using Plerixafor/mozobil and its a big argument between hospital administration vs insurance who pays for it. You are talking a cost of approx $5000 per day (single use vial). Insurance wants to bundle it into the case rate and hospital wants to get paid for it separately since its not standard of care yet. We have only been using it on patients so far that would never have been able to mobilize enough for even a single transplant. It's also been a hassle logistically for dosing since the drug reps suggest it be given 10 hours before start of harvest, which either means the patient is on our same day unit with a nurse on OT at 10pm at night being observed while getting the drug - or our apheresis nurses would have to do something like start collection at 3 am. Not too reasonable.

At our institution (adult transplant only) the stated acceptable peripheral CD34 count is 10. Only patients who have to be mobilized off of chemo in combination with gcsf get peripheral counts to determine harvest timing. "Normal" patients mobilized on gcsf alone do not get counts, they simply get collected starting on day 4 gcsf. Our donor program is often browbeaten into collecting at a 6 or 8 peripheral CD34 because "We're sure it will be higher tomorrow". From a processing lab standpoint it seems that results in an unnecessary day of harvest 75% of the time, but there is that minority of patients with extensive pretreatment (revlamid/irradiation) where you end up needing every scrap collected. Judgement of your transplant coordinator/medical director is needed to determine those exceptions where it will be worthwhile for the patient.