AuntiS

I really enjoyed this talk!

I really enjoyed this talk!

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Cerner allows us to extend the date of the Preassess sample. If no pregnancy or transfusions, and a prior history or second sample drawn for confirmation of ABO/Rh, sample good for 4 days with OR day being day one. Not to surpass 30 days sample date. EXM still applies when sample date is extended.

Thank you all very much for your responses. I'm glad to hear that this is not a common practice and I do agree that the risk of mistyping would be extremely rare. This was my first time as well seeing this kind of practice.  Definitely worth an SOP change. 
 

Not a sensible approach in my opinion.  No real chance of mistyping due to fetal bleed.  At very least, you'd see a mixed field if there were a fetal bleed with a different type.  So get rid of this requirement in my view.

I've been Blood Banking for 35 years......... (albeit in the same hospital) but I've never heard of that - nor do I know of any AABB or CAP regs that would imply that...... (and we've just been inspected by both!)

I've never heard of that.  While I can understand the rationale, I'm afraid that if there was enough of a fetal bleed to impact antigen testing mom there are bigger problems than just getting the antigen type right.  Just my thoughts.

 

You did everything necessary as others have said. At our facility, physicians seem to be unphased by the use of emergency released blood - we issue a lot of it.  It is not uncommon to discover that the patient has a historical antibody that may or may not be demonstrating. The physician and pathologist are notified when the history is discovered and the physician makes the medical decision to continue or stop the transfusion at that point. We perform antigen testing of the unit(s) and perform AHG compatibility testing of all units that are issued.  Further laboratory testing is ordered by the physicians caring for the patient. The most immediate concern is an acute hemolytic reaction and that is rare. Shortened survival of incompatible transfused red cells is expected.

Agree! Save the life first.
Our medical director would likely order at least one DAT the next day, possibly for additional days, to monitor. Anti-E is generally relative benign (though I have seen one patient who had an acute hemolytic reaction), We might also monitor plasma Hgb or haptoglobin, depending on the antibody involved.

You did everything that was required in this situation. The patient was a trauma and needed emergency transfusion. The risk of death outweighed the risk of a hemolytic transfusion reaction in that scenario, according to the treating physician. I once had a trauma surgeon tell me "I can treat a transfusion reaction but I can't treat death!" That put things in perspective for me. That is why thy sign the consent.
Next step would be to report this to your risk management department so that follow-up can be made, including monitoring the patient for the s/s of DTR. 

Always great advice from Malcolm
I find the use of anti-A,B is helpful - especially when the red cells from cord blood react weakly with the anti-A (which we know can be underdeveloped).  We accept weaker reactions in newborn samples than we do for adult blood samples.  However, that being said, if there is any doubt - we will not report the ABO group (often the Rh is needed for RhIG requirements) and give group O blood if a transfusion is required.
sandra

Always great advice from Malcolm
I find the use of anti-A,B is helpful - especially when the red cells from cord blood react weakly with the anti-A (which we know can be underdeveloped).  We accept weaker reactions in newborn samples than we do for adult blood samples.  However, that being said, if there is any doubt - we will not report the ABO group (often the Rh is needed for RhIG requirements) and give group O blood if a transfusion is required.
sandra

I think the transfused cells were at the bottom rather than the top.  The analyzer samples from the bottom, I think.

That is correct Mabel Adams. Thank you for clarifying that. Transfused cells are more heavier that autologous cells, and therefore they reside at the bottom of tube after centrifugation. The probe in Erytra analyzer picks up the cells 2mm from the bottom of the tube.

Hi mpmiola,
I apologize for my late reply.
Grifols just confirmed the phenomenon that was described in the discussion above as the cause of the ABO discrepancy. They stated that the probe in Erytra analyzer goes down to 2mm from the bottom of the tube to pick up red cells. in this case, the transfused cells (group O) are more heavier (more dense) than the patient's own cells (group A) and therefore they occupied the bottom of the tube after centrifugation.  Since the probe only takes cells from the bottom of the tube, it only picked up the transfused cells (group O).
Hope this makes it  clear to everyone.
 
 
 

The first, and most important, thing to remember is that ABO antigens are "carbohydrate-based" and are not, therefore, direct gene products (not that any antigens are, as every one of them undergo post-translational changes).  The direct gene products are, of course, the A,  B and H transferase enzymes.  At birth, it is incredibly rare for the enzymes to be "working" at its optimum/maximum, so that it is rare for the ABO antigens to be expressed maximally (or anything like) at birth.  I am certain that you know all this already, so that I am probably "teaching my Grandmother to suck eggs", as the old (and in this case, almost certainly, insulting) adage goes.

As a result of the above, however, unless you can perform A, B and H typing by molecular techniques (NOT to be recommended - see Geoff Daniels book, Human Blood Groups), you either have to decide to ignore all serological cord ABO types, and call all of them O, or, you have to use serological methods that will enhance the antibody/antigen reactions.  Herein, there are inherent problems.

Firstly, whatever enhancement you use, you MUST use a suitable negative control.  It is fine (in my opinion) to vary the incubation temperature from RT to 4oC, but, to so do, it is very necessary to use another cord blood from a known group O cord sample (i.e. where both parents are KNOWN to be group O themselves, and so an A or B subtype in terms of the control is not a problem).

Similarly, the same can be said for enzyme-treating the baby's red cells, as long as the control cells are also treated in EXACTLY the same way with the proteolytic enzymes.

Finally (at least for now!!!!!!!), it should be remembered that we routinely use monoclonal ABO antibodies these days.  These are extremely avid, which is fantastic, but are also VERY specific, which can be a drawback.  By this I mean that the old polyclonal human-derived ABO antibodies we used to use (when I was middle-aged, and Karl Landsteiner was a young boy) had the single (and probably only) advantage that they were not quite so specific, and would, therefore, detect ALL (or most) ABO antigens, including those that the monoclonal antibodies would not necessarily detect.  For an explanation of this, there was a recent paper in Vox Sanguinis (Cripps K, Mullanfiroze K, Hill A, Moss R, Kricke S.  Prevalence of adsorbed A antigen onto donor-derived group O red cells in children following stem cell transplantation: A single-centre evaluation.  Vox Sang 2023; 118: 153-159.  DOI: 10.1111/vox.13386) talking about the A antigen being adsorbed onto the surface of group O red cells in vivo.  One of the references they use is the first peer reviewed paper that I ever wrote, concerning A and/or B substance being adsorbed onto the surface of donor-derived red cells in vivo.  What I failed to say in this paper was that this phenomenon was far easier to detect with polyclonal ABO reagents than monoclonal ABO reagents (36 years, and I still regret this omission!).

Anyway, IF I HAVEN'T SENT YOU TO SLEEP YET, my point is that, as long as you use suitable controls, particularly NEGATIVE controls, there is no reason why you should not use any modification to any technique (GIVEN THAT IT IS IN YOUR SOP, with all the qualifications given above), and, even then, if you feel it safer, GIVE GROUP O BLOOD.

Just to be clear, these regulations are almost totally arbitrary and can be overridden by a physician's judgement.  There are no data to support this 30 minutes nonsense nor the 1-10 degree storage requirement.  Just so we all understand there is almost no scientific or clinical basis for our regulatory rigidity and we are usually discarding perfectly safe units of blood.  Rant off :).

To quote my first BB manager “first rule of BB; get the ABO right, last rule of BB; get the ABO right. “

We don't recheck antigen typings here in our hospital in Canada. The typings that have been performed at Canadian Blood Services, are embedded in the barcode on the bag, with all negatives printed on the End User Label. Every unit is antigen typed for K so if it isn't printed on the bag the unit is K Pos. Antigen typings we do are all linked to the unit through barcode. The reason of, "We were typing a lot of units and may have mixed them up", is not acceptable in a blood bank setting. Go work in a different department if you can't organize yourself. Anyway, there is also a full gel or whatever you use crossmatch at the end of that phenotyping, as long as the antibody is reacting, an anomaly could be discovered there. You have to have a little faith that people before you are doing their job properly, or you can cause yourself a lot of undue stress.

There was a study done here by ORBCoN in Ontario, Canada.  It showed that most (I think it was 99%) babies were delivered from people under the age of 46.  So yes, not all.  But most.
Best of luck on your journey to conceive.  I had mine at 40.  So I'm always tired, but love her to bits.

There was a study done here by ORBCoN in Ontario, Canada.  It showed that most (I think it was 99%) babies were delivered from people under the age of 46.  So yes, not all.  But most.
Best of luck on your journey to conceive.  I had mine at 40.  So I'm always tired, but love her to bits.

There was a study done here by ORBCoN in Ontario, Canada.  It showed that most (I think it was 99%) babies were delivered from people under the age of 46.  So yes, not all.  But most.
Best of luck on your journey to conceive.  I had mine at 40.  So I'm always tired, but love her to bits.

Here is my old validation.   Hope it helps
 
Validation of the Electronic Crossmatch at the GGH - signed.pdf

There was a study done here by ORBCoN in Ontario, Canada.  It showed that most (I think it was 99%) babies were delivered from people under the age of 46.  So yes, not all.  But most.
Best of luck on your journey to conceive.  I had mine at 40.  So I'm always tired, but love her to bits.