Vic

This patient has since left and now has returned along with an Anti - Kell! Her DAT is still negative, tube and gel.

100% Agree!! Our OR does have a process for this and we actually have a policy stating that it is the OR's responsibility to own that process, not the labs.

Her haptoglobin pre and post transfusion was 2. Her H/H did continue to fall, but it is unknown as to wether it is her active bleed or hemolysis. She did reach 9.5 prior to discharge. We could not find a transfusion history on her, locally. I will look more into her meds just for my own curiosity. She was shipped out to a larger hospital and they repeated her workup as well. Nothing new discovered so that is good.

What if the transfusion is stopped because of something happening to the IV? For example, the patient pulls the IV out. Can a new IV be inserted and the transfusion continue? Is there a risk of bacterial contamination at that point? I am not very familiar with how an IV is hooked up to a unit so feel free to inform me!:tongue:

Hi! Just wanted some input on this situation..... 58 yr old female presented to the ER on Friday, 3/11 with : hemoglobin of 4.4 g/dL, 12.9% BUN 45 mg/dL Creat 2.30 mg/dL Trpn 0.2 ng/mL Total Bili - 0.5 mg/dL The patient is admitted for chest pain, acute renal failure and anemia. She is typed and screened for 2 units of PRBC's. Screen result is negative, crossmatch is compatible (using gel). Plasma appears to be a light gray color as it is slightly lipemic. First unit is issued around 0700, 3/11. Cardiac collected at 1020, 3/11 shows troponin of 0.8, 1620 - 2.1, 2235 - 3.8. Plasma now appears to be a dark brown/green color. Tech questions serum appearance and calls the nurse to check on the status of the patient and is told she is exhibiting no signs of a transfusion reaction (other than chest pain). Over 2 days, the lab observes the patients labwork and notices her: Total bili increases to 2.1 Indirect bili increases from 0.3 to 1.6 BUN increases to 53 LDH is 1909 (haptoglobin levels are being tested now, will update when I get a result) plasma appears to be getting darker/more brown/red color urine shows 4+ hemoglobin with only 2-5 RBC's per high power field Techs start getting worried that the patient is in fact having a transfusion reaction so they repeat the screen (still negative) and perform a Polyspecific DAT (which is negative). The pathologist is contacted just in case. So...what is your thoughts? Is it possible for something along the lines of compliment and we just can't detect it because of the gel being IgG plus the fact that we use EDTA plasma for testing? I have been reading up where a DAT can be negative during a HTR. Is all this just her renal failure/meds? :confused::confused:

Here is my question... CAP standard TRM.40500 states....."This may not exceed 3 days in patients who have been transfused or pregnant within the past 3 months, or if relevant medical/transfusion history is unknown or uncertain." AABB standard 5.13.3.2 also has similar wording. So...how can you be certain of a patients history? Is having them sign a form really adequate? Some patients would not be able to confirm or deny a transfusion as they do not rightfully know. Some would even sign the form saying they had not been transfused when in fact they have. The same could be said for pregnancies. I ask this because I was asked this. I recently took the role as supervisor of our blood bank and for many years...the lab has collected a pre-admit specimen after asking -have you been transfused/pregnant in last 3 months. The type and screen is done the day of collection but (as long as there are no antibodies or history of) the crossmatch is done the day prior to surgery which could be 3 or 4 days later (but no sample is used past 7 days here). It was suggested to me that we keep preforming the pre-op type and screen as we do but then recollect the day of surgery to perform the crossmatch. Would you have to repeat screening test? What about arm-bands, do you re-band the patient? Does anyone else do this? Any input is appreciated.

If what you are referring to in TRM.43650 is the "NOTE: If a sterile connecting device is used, the integrity of the weld and maintenance of the closed system must be assessed and documented after each weld." and you are not using a sterile connecting device, then this note does not apply. Great! Thanks for clearing that up for me!! I just needed another point of view.

We currently use the small metal clips and a crimper to seal off a unit after splitting it. I was told by the Quality department at the ARC that by placing two clips on each side of a cut, the unit would maintain sterility up to the expiration date on the bag. TRM.43650 states that there has to be procedures for maintaining sterility and the weld and maintenance of the closed system be assessed and documented after each weld. Does anyone else do this? If so, how do you document? What are you documenting? We only do this maybe once or twice a year as we are a small facility and we can not get a heat sealer. Any help is appreciated. Thanks!

How exactly did you validate your saline? We are currently undergoing the same change and I am just wondering how you did yours.

I have been fighting off the Ortho Rep for about a year now because he would like for us to evaluate the ABO/Rh gel cards. Simply put, I can do an ABO/Rh less than 5 minutes, the gel takes 10 just to centrifuge the card. If we are doing a crossmatch on someone with no previous record, you have to wait at least 15 minutes before you even know what their type is. You also introduce a new diluent into the mix as well so I worry about the techs mixing them up (not sure what the difference in the two are). All of the techs here are generalist and there is not a tech dedicated to just blood bank so use of time is important here. I will continue to use tube for as long as I can. Just my 2-cents!

We charge a "Bill for Thawing" only if the unit is ordered and not transfused.

I have a book... Guidelines for Prenatal and Perinatal Immunohematology, published by the AABB that actually states "Only when prenatal tests for Rh are unequivocal and clearly reactive (>/= 2+) should the woman be considered Rh-positive." For this reason, we do not do weak D testing on mothers, only the infant, and the mothers get Rhogam if indicated. I tend to run into problems with the State Lab which still considers all weak D patients to be Rh positive. They do a lot of our OB patients during prenatal care so every now and then we get that one patient that is "Rh Positive" yet we call her "Rh negative" and she gets Rhogam provided she meets all other criteria. I tried to consult with the director of the State Lab but she basically called me an idiot so that conversation ended quickly.

We test our check cells against the saline as our check cell qc. Don't forget about your MTS diluent to, the package insert for that states it should be QC'd to.

We have currently switched all of our ABO typing and antisera's to Biotest. I find no real difference in performance. I did, however, find that the poly AHG did not react as well with complement as I would expect. There is not a room temperature incubation after the immediate spin read so I am not sure if that may be weaking the reactions. We will probably not be using the poly reagent. We did a comparison of 20 patients (we are a small rural hospital) for the ABO reagents and only one for each antisera (due to high cost of reagent).

Of course, I always love the "You had to go to school to do this?" comment from nursing.:mad: Although I wonder.......I once had a tech call me at home to ask if they could use a hemolyzed specimen to do a type and screen. I told him what procedure to read and went back to sleep. Hot dog from the lunch room: $1.00 Sterile urine cup with saline and falsely completed order form: $3.00 Look on the face of the new male co-worker that thinks he has to set up a tissue culture (and use the grinder): Priceless!!!

Positive antibody screen called to nursing staff....nurse replies..."Thats ok, she's on antibiotics" Drawing a patients blood while the nurse is explaining to her that the Rhogam injection is going to "change your blood type so that it is compatible with the baby". Diagnosis...Bee Sting....complete vaginal workup performed... Nurse stands at the specimen drop off counter, rocking a CBC back and forth while stating "I hope this isn't clotted, she is a very hard stick". I go over to check it out, when I rock the tube, the blood does not move at ALL! Completely clotted. Wonder what he was looking for?

In cases like this, would any of you consider giving Rh Immune Globulin? At what point would you?

This is how we handle this issue: Our computer system is attached to 5 other hospitals in our system. First we do a history check by SSN to check at the other hospitals (one of which is very large) for any historical type. If there is not historical type and the patient is not group O AND red cells or FFP is ordered, then we have to have a second sample. We can have a sample that was collected up to 7 days prior as long as it was collected at a seperate time. If one is not available, we have the nurses collect a CBC tube (not a blood bank one, that just confuses them). If there is not time for a recollect then we opt to give type O. Our computer system allows us to order a ABO Second Sample test as well as stop units from being issued until this ABOSS test is done. If the patient is type O then we do not do any kind of confirmatory testing. Now, We just had our CAP inspection in Feb. My inspector asked me "How do you know that the second sample is being collected from the right patient?". So, how exactly do you argue that? She was actually going to cite me because we, the lab, did not go to the floor and draw another specimen, regardless if we already had a seperate one in the lab. I took her to our QM department and discussed the education and training we perform and the corrective action taken when any specimen is mislabeled. She still wanted to cite me....so..luckily there was a CAP inspector with her and I asked her. She agree'd with me that what we were doing was sufficient. Apparently my inspector was cited because they did not draw the specimens and she wanted to get me for it to. So...beware!:tongue:

We use a 150micron filter and syringe adapter for Neonatal/Pediatric transfusions. (Charter medical product) We issue the filter with the blood and let nursing take it from there.

Currently, our Blood Bank is the one that drops the "blood administration" charge for our hospital. 2 days after the product is issued, our computer system puts the product in "Issued, Final" status. We are able to print a report which shows all of the products that were issued 2 days prior and then we charge the patient based on the amount of time transfused, < 2 hours, 2-4 hours or >4 hours.

We have gone through our last 3 CAP inspections not performing IS crossmatches. We only use the gel for routine crossmatches and we have yet to be cited. Our computer system will also not allow ABO incompatible allocations.

No, it did not appear hazy, it generally looked like a weak 1+.

Thank you for the responses!

I work at a small hospital that performs limited testing. We use the gel card and that is about it. We do not keep any antibody tube testing reagents in house. We recently had a patient that had 3 non-specific reactions on a 11-cell panel. All clinically significant antibodies are ruled out but the antibody was reported as a Non-specific Cold. My problem now is, the pathologist was informed that the patient had a cold auto and he requested that a blood warmer be used(which we rarely use). Would you have reported this as a cold? How can you tell it is a cold just using the gel card? Wouldn't Antibody with no Apparent Specificity be a better ID? My suggestion would be to just give crossmatch compatible red cells and not use a warmer, what am I missing? Thanks!