Kathy

The patient stated that he has NOT been transfused anywhere in the past 3 months.

Thank you. Our transfusion director has spoken with the patient's physician and requested a peripheral smear, but I don't see any mention in the chart about suspicion of relapse. The patient is an outpatient with cGVHD who comes in for photopheresis.

What about neutralizations?

Is there anything I can do to resolve this? Would adsorption and elution be helpful?

Thanks for the input. Very good information. The patient's physician is investigating a possible relapse. The suggestion that the patient may have been transfused elsewhere is a good one, but it wouldn't explain the strongly positive D typing, which is that of the patient's donor. A relapse would involve both the ABO and the Rh types, would it not?

We have a patient who is now typing as A positive (2+ with gel and tube in the forward A type, no mixed field, 4+ with anti-D, no mixed field). This patient was originally A negative and had a bone marrow transplant in 2010 from a type O Positive donor. The patient fully converted to a type O Pos forward type as of 2015, but never made anti-A (this happens, I understand, so I'm not concerned about it). I would maybe think the patient was relapsing to his prior A blood type, but that does not explain the D+ typing. I would expect to see mixed field reactions if the patient was relapsing as well. I did run his cells against the plasma of three type B patients, and the result was negative. I typed his cells with 5 different anti-A antisera from 4 different manufacturers, three of which gave positive results and two were negative. I did not test with A1 lectin. Any idea what is going on here?

Thank you!

What is the prevailing thought regarding the quality of platelet products stored with bubbles or foam? I found two articles that concluded that "storage with air bubbles/foam causes considerable enhancement of disintegration of platelets".

We definitely see the specks as well. We got the 'upgrade' a few weeks ago. It's great that we can now put half used IgG cards back on the instrument and we can change QC results, but we are having worse problems than ever with the instrument not knowing what to call things or calling them 1+ when they are really negative. We have verified the 1+ reactions as negative with manual gel testing.

You can't change a QC result because that's how the Ortho people programmed the instrument. You are allowed to change patient reaction results. The software update will allow users to change the QC result.

This does not answer the original question, since we are interfaced with Softbank, but I am going to warn you to the potential problems that are in store for you: We have had two of these instruments up and running since August. Here are the problems we have: 1. QC is a pain. Half the time it does not pass because the instrument can't interpret the image. You can't change the result, so you have to rerun the QC. Sometimes you have to rerun it multiple times. It can take half the day just to get the QC to work and there have been times that the QC has timed out on both instruments and we have had to resort to manual testing. Not good for a busy hospital like ours. There is a software update in the works that will allow techs to manually interpret the image, but I feel this is a bandaid on a bigger problem, which is the sensitivity of the instrument to artifacts (see below). 2. The instrument is extremely sensitive, so even dust will cause it not to be able to interpret images. Techs manually have to change the grade. 3. After centrifugation of the cards, we will sometimes see streaks of cells up both sides of the well, but not in the center. The instrument will interpret this as positive, but we have learned through experience that if we repeat with manual gel testing, it will be a nice negative result. We never saw this happen with the ProVue and I wonder if it is a problem with the centrifuge. Perhaps if it used a balance card, we wouldn't have this problem. It's just my theory. 4. You can't put partially used cards back on the instrument. It causes a lot of waste. Also having to repeat QC so many times is wasteful. 5. Aside from the above problems, we love the instrument.

Thanks. I need to make 0.2M DTT, but I need to make the PBS first. I ended up ordering this PBS with pH 7.3: http://www.lonza.com/products-services/bio-research/cell-culture-products/reagents/buffered-saline/pbs-without-ca-mg-or-phenol-red.aspx and this DTT: http://www.gelifesciences.com/webapp/wcs/stores/servlet/ProductDisplay?categoryId=11093&catalogId=10101&productId=22063&storeId=11787&langId=-1 One of my coworkers found an SOP that calls for adding 1 g of DTT to 32 ml PBS. When the chemicals arrive I will try that and check the pH. Unfortunately, we don't have a high-accuracy scale for weighing dry chemicals, so I needed to order the everything as much pre-measured as possible. Stay tuned....

Does anyone have a recipe for making the DTT solution for treating RBCs? The AABB Technical Manual says to "prepare 0.2M DTT by disolving 1 g of DTT powder in 32 ml of phosphate buffered saline (PBS), pH 8.0". I cannot find a source of PBS with a pH of 8.0. Do I need to buy phosphate buffer with a pH of 8.0, add it to saline, and then add the DTT powder?

I spent 24 years working in 2 pediatric hospitals with level 3 NICUs and can count on one hand the number of times I or any of my colleagues did the procedure. I doubt there is any hospital that does a lot of them. For competency, you can save up expired RBCs and FFP so that you can do a direct observation. Make sure their final product has the target hematocrit. I would also make a thorough written quiz for assessment of problem solving skills.

There are no cost effective disposable temperature monitors for platelets that you can stick on the units that I am aware of. I know that Berlinger makes something that you could have custom made for the 20-24 degree range...cheapest would be about $10 each (Q-Tag, I think), so a bit pricey. I think the best option is to validate coolers for platelets - you can beef up a standard cooler with Styrofoam, room temp gel packs, etc. and then use a temperature datalogger in the cooler - preferably with an alarm. I like the Traceable Memory-Loc ones because you can transfer the temp data on USB if needed. I want the platelets back ASAP... CAP says something about not being agitated for up to 24 hours is acceptable, so you will want to define how long it is OK to be out of the blood bank in your SOP.

I am in a pediatric hospital and we give irradiated to all NICU patients and DiGeorge syndrome patients. We don't have our own irradiator and we do sterile connect. We will assign one unit to a few patients and use it for those patients until it is gone or it expires, whichever comes first. Blood for surgeries or exchange transfusions for babies has to be less than 5 days old.

If I have the techs check the diagnosis and call the doc and ask if they want to change it, should I also have some means of the techs documenting that they checked the diagnosis and that it did or did not meet our irradiation requirements? The admitting diagnosis is printed out on blood product orders. Maybe I should have them initial next to the diagnosis that they checked it?

How much responsibility should the blood bank take on to avoid transfusing non-irradiated blood to new patients who require irradiated blood? Should the blood bank check the diagnosis of every new patient when a type and screen is ordered and place an irradiated blood requirement in the computer system if the diagnosis is one that would require irradiated blood, even if the physician doesn't order it? If the blood bank takes on this responsibility, what happens if something gets through the cracks? Is the blood bank liable or is the physician? I have read other threads similar to this topic, but not specifically dealing with new patients with no history or alerts.

We do have a "happy meal" type of system for the first 4 units, which works fine in some situations. The problem comes when the patient is bleeding faster than we can tag units. Our computer system is a real pain when it comes to emergency issue because there has to be some kind of blood bank order in the system in order for us to be able to issue blood to a patient. It takes time to figure out if that order exists and then to place the order so that we can issue blood. Fortunately, we are going live in 3 months with a new system that is much more "emergency issue" friendly. Until then, we may have to consider not tagging units for exsanguinating patients.

If you have an exsanguinating patient, what is the absolute minimum you need to do to get the type O blood out the door? It seems like the tagging process takes up precious time with our current computer system. Can we just slap "uncrossmatched blood" stickers on the units, pull the segments, pull a unit numbers from the units, and send the units untagged? Do we have to sign the tags that we did a clerical/visual check when we issue? Perhaps we can have the ER bring patient labels with them so that we can put those plus "uncrossmatched blood" stickers on the units?

Thanks. We are having a problem with our new LIS company not including the hospital name on their standard tags, which forces us to pay to have them customized so that we have our name and address on them. We are trying to make a case that that should be standard because it is required.

Is the facility name required to be on the compatibility/component tag? If so, which regulatory agency requires this and where can I find it?

The Technical Manual is a bit inconsistent. On page 283 it says "Cellular components stored in syringes have an expiration of 4 hours." On page 284, it gives us conflicting information, this time in reference to platelets: "The 6-hour expiration time is acceptable for syringe aliquoting using a closed system". Syringe/filter manufacturers have given me even more conflicting information, stating that 24 hours is acceptable. Apparently, adding a syringe/filter on using a sterile connection device does not create an open system (unless the weld leaks), but the shortened expiration of the product in the syringe is due to the potential for formation of microaggregates between the filtration time and the time the product is transfused. We sterile connect syringe/filters and give the syringe product 24 hours for RBCs and FFP, 4 hours for platelets.

I agree that this is a very daunting task and I don't know where I'm going to find the time to do the direct observation on all tests for everyone, especially with a new computer system validation and launch coming up soon. I have a few techs on the evening shift who have Florida blood bank supervisor's licenses, so I am going to see if I can delegate some of those tasks to them, after I do the direct observation on them. I have competency files on all of my techs and whenever I just so happen to observe them doing anything, I write it down in their files. That saves me a little time. I have made a customized course (quiz) on the CAP website, which assesses their knowledge of our policies and procedures. I have the AABB publication that has observation checklists and competency assessments, so I will use them as a starting point. I really don't understand what intermediate worksheets are. If someone could clarify, I would appreciate it.

Our billing guru told me that we can't bill for leukoreduced, irradiated, platelet pheresis + HLA coordination fee. Apparently there is no HLA coordination fee billing code. Is this correct? If there is no code and the product is ordered but not used, is there no way to get reimbursed for that enormous fee that we are charged by our supplier? I am a bit dismayed that there is a HCPCS for leukoreduced HLA matched platelets, but not for the same irradiated product. By virtue of it being HLA matched, it must be irradiated. So we would have to bill for the irradiation separately. And then it becomes very complicated because when you scan in the platelet pheresis unit that is irradiated, HLA matched, the E code is for irradiated, leukoreduced platelet pheresis. We will have to credit the HCPCS code associated with that product and manually bill the HLA product + Irradiation. What a mess! And while I am on my tirade, why is there no HCPCS code for Irradiated Granulocytes? Seems to me that by virtue of your patient needing granulocytes, they are at risk for graft-vs-host disease and therefore need irradiated granulocytes.