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Posts posted by SMILLER
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2 hours ago, jayinsat said:
Does the patient have thrombocytopenia? Could they possibly be treating him for ITP using WinRho?
No and no.
Scott
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We currently have a 50 year old male in house that had an accident that damaged his foot 3 weeks ago. He arrived septic and has had to have an amputation.
His ABO/Rh gives a B pos with a 4+ anti-D. His gel screen and panel give 1+ results that match up with an anti-D (all others rules out). His autocontrol was positive at 1+ by IgG, neg for compliment. The eluate results matched the original antibody ID. Presently this patient's specimen is on its way to our reference lab. Previous history at another facility lists him as B Pos, screen negative. As far as we know, he has never been transfused.
What are the possibilities (for what appears to be an D auto antibody), and how should he be treated?
Scott
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Just as a side note (see my post, above), our BB computer system is used by 3 hospitals with two different medical directors and CLIA numbers.
Whatever you want to do, you should probably talk to someone at an agency that does your inspections.
Scott
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Like many systems, we have an ancillary center where all of our outpatient transfusions are performed. Other than releasing products form the BB computer system, they do no testing at all. We ship units from our inventory to them after appropriate compatibility testing. We do all testing at the hospital.
We also have two smaller hospitals within our regional system (Ascension), that share our BB computer system. On occasion, they send short-dated units to us. We do not re-type these units. Note that the initial unit typing, whether here or at a sister hospital, is recorded on the same BB computer system. We are FDA/JCAHO inspected.
Scott
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Someone here will have better suggests than me. In the meantime, we will need more information.
Did the patient have a prior history?
What antibody was ID'd two months ago? (some antibody titres, like Kidd, can go up and down)
If the most recent screen (from "1 week ago") was positive, what happened with the antibody ID testing?
Also, what techniques are you using?
If your current ID testing is inconclusive, and you have exhausted all of your methods, then you need to send a specimen to a reference lab. Even if the patient is not going to receive blood currently, you will want to know what is going on for future reference.
Regardless of current antibody ID, at the least, you will need to screen units for that antigen because of the ID from 2 months ago.
Scott
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We use the Ortho confidence system with manual gel. We have found that a dilution of 5 drops of Ortho diluent plus 5 drops of 22% albumin plus 50 ul of confidence sera works pretty well to produce 2+ to 3+ reactions.
Scott
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From our experience, both negative and positive reactions should give a reasonable clearly delineated button after 15 seconds or so. (If you spin patients for 2 minutes, I would think that you would end up with a lot of "snotty" false positives!)
Is your centrifuge running at the correct centrifugal force? Is it vibrating too much? You may want to try the process with another centrifuge just to see if there is something wrong with what you are working with in the Blood Bank.
Scott
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We allow other areas to change BB armbands. We have a form for that that is returned to the BB so we can make the proper adjustments to the specimen ID, tags, computer, etc.
Scott
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With a few exceptions, only Lab phlebots draw BB specimens here. And we have our own BB armbanding system.
Scott
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Of course. There is no link between a previous admission and a current one that is reliable enough to allow for transfusion of any product without at least confirming the ABO/Rh. We have even had a few patients who have been admitted with a friend or relative's ID in order to piggy-back on insurance!
Scott
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On 6/7/2019 at 4:58 PM, Dansket said:
Testing the same specimen twice may detect some internal testing errors, but will not detect WBIT (Wrong Blood In Tube).
You need to gather some data to show how many patients would be impacted by collecting a second blood sample.
Ask these questions, "How many patient admits annually?", "How many patient admits required blood bank testing?" (at my facility the calculated percentage was 11%), "How many patient samples type as Group O?" (at my facility the calculated percentage was 55% and we don't draw a second blood sample on these patients), "Of the non-Group O patients, how many had an independently collected blood sample in Hematology that could be used for the second ABO blood sample" (in our facility that was calculated to be 16%).
So for every 1000 patients admitted annually, 100 (I'm using 10% for sake of simple calculations) would require blood bank testing of whom 45 (100-55) would be non-group O, 7 (45 x 0.16) would have a blood sample in hematology, leaving 38 (45 - 7) or 3.8% (38/1000) patients requiring a second sample to be collected.
Using this kind of data will give you a much better grasp of the impact of routine performance of a second ABO determination on all patients for whom a Type and Screen or a Type and Crossmatch is ordered.
I do not think there is any way to always avoid WBIT. If a particular error in patient or specimen ID can be made once, it can be repeated. What a second specimen does is verify that the two specimens are the same ABO/Rh--which is good enough to avoid an ABO acute hemolytic transfusion reaction.
Using a BB armband P&P properly will assure you that the blood you are testing and the patient it is being tested are the same--even if the patient ID is wrong.
Scott
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We do not test a different specimen. Currently regulators in the US only require a second ABO test (in order to release "electronic crossmatched" units). We test the same specimen twice, unless we have a previous record.
However, we DO use a BB armband specific for BB specimen draws and transfusions. The phlebotomist applies it and it must be used when ordering, issuing and transfusing blood products.
Scott
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Agree! I am optimistic that as the data gets discussed more at various conferences and seminars, that we can move on to improvements on the supply side for those facilities who do not have the luxury of running their own donation service.
Scott
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We are a trauma-2 hospital in a reasonably populated area in mid-state Michigan. Our hospital has 270 beds, and is busy with a number of neuro and CA patients, along with an open-heart program. There are two other hospitals nearby who are also busy, but not nearly as busy as a big medical center like U of M in Ann Arbor. So we have these utilization issues. I wonder how many other hospitals have the same limitations.
We already have problems (like in December) of obtaining any platelets at times, much less ABO matched. We normally only keep one 5-pack on hand for traumas, and we take what we can get, with the only exception being for females of child-bearing years.
Citations are not going to fix this no matter how good an idea it may be.
Scott
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1 hour ago, sgrassley said:
Back in the day when we had a whole blood inventory, we would just express the plasma from the red cells after they had settled out in the refrigerator without centrifuging. The theory was there was enough plasma left with the red cells and hematocrit wasn't too high.
We still do this once and a while for autologous WB units. But if you have to enter the unit to split it, then that cuts the outdate down to 24 hrs. You would have to be sure to have satellite packs for WB units.
As far as the "salvage plasma", you can simply fractionate it and use it for gamma globulin!
Scott
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I don't think so. It's not like charging for a antibody ID after getting a positive screen. It would be more like repeating a charge for, say, a potassium because the analyzer failed on running it the first time. So I would say no, you cannot bill again.
Scott
- Dansket and John C. Staley
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From Neil's post above:
"ABO type platelets and so-called "universal donor" AB plasma for all patients is highly toxic due to formation of ABO immune complexes in every patient we give this cocktail to"
Is there any data on this? What ABO immune complexes are being formed from the transfusion of O pRBCs and AB plasma (which is the typical way to treat bleeding trauma patients)?
Interesting concepts though, even though some of the "data" in these articles is a mixture of speculative opinion and retrospective study results from rather small cohorts. It will be interesting to see how this progresses!
Scott
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18 minutes ago, cswickard said:
Does the O.R ever tell you that the Pt's armband is "inaccessible" because it is "under the patient and contained within the sterile field"? We use an armband system for our BB patients and we get told that occasionally when we need to transfuse in O.R. and they didn't get the armband number before they covered up the pt. The RN usually winds up crawling under the pt's table. What does your O.R do in that case? Especially since they are having to do a barcode read of that band?
We use coolers for our O.R. deliveries (one pt per room) and I never want to even discuss the introduction of an O.R. refrigerator. Anything giving in the O.R. is documented in the anesthesiologist"s records, which are also part of the electronic record.
We had situations like you describe a few years back. Now checking the Blood Bank (and hospital) armbands are part of the "time-out" check-off before the patient is strapped to the table. The ID info on the bands are recorded so it is available at all times during the procedure.
Scott
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On 5/21/2019 at 1:40 AM, Dansket said:
Could the Daily/Day of Use QC for the ABO Plasma Grouping Cells ( A1 and B ) be considered a positive and negative control for the saline crossmatch? In both cases these tests use patient serum/plasma added to donor red cells, the only difference being that the ABO Plasma Grouping cells are stored in solution designed to maintain agglutinability while the donor cells are stored in a solution designed to maintain oxygen transport.
If I understand the question, I think that you could say that any negative reverse reaction on the patient's ABO typing would serve as a negative control--however, this would not be good enough for O patients. For a positive control, you would likewise be stuck on AB patients. But I do not think that patient specimens are regulated as "QC-able" materials in the case of a IS XM.
Regardless, I would think that the "pos/neg" QC regulations are concerned with validating reagent reactivity and system integrity, and not so much with one patient's specimen reacting with another's RBCS.
Scott
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Agree with John's points, above.
I am not sure I have ever heard of a person doing ANY non-waived Lab testing without having earned a degree specifically in medical lab science. Even with that, you would have to have passed a national board exam in the US. Possibly there have been people grandfathered under certain circumstances?
Regardless, the thing about training is, I can train a high school student to perform the steps to start a test or do routine maintenance in a Lab. But they would not have the education required to understand what "it all means", which is essential in pretty much any healthcare profession--especially one so technical as Lab Science.
You may, indeed, have earned credits in inorganic and organic chem, microbiology, etc, but if you look at a certified program for a MLS (or MLT for that matter) you will see that beyond basic biology and chemistry, there are a load of specific courses that must be completed as the professional part of such a degree. A general biology degree (or any other type of degree for that matter), whether AAS, BS, MS or PhD, does NOT qualify a person to perform most of the functions done by a Lab Tech.
Scott
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On 5/22/2019 at 6:21 PM, Dansket said:
Are you saying that because the ABO Determination test is self-validating, that those test results can also be interpreted as ‘negative’ QC for the reagent red blood cells and the reagent antisera? Extending that logic, then why can’t those same test results also be interpreted as Positive QC for both sets of reagents!
Please help me to understand. Is there any precedent in laboratory medicine for a test to be considered self-qc'ing (I know this isn't a valid word) and therefore not requiring separate positive and negative controls?
No. I was being the devil's advocate for other posters in that post. We have been using pos and neg control material for all of our ABO reagents for many years.
Scott
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I think you could define the"test" as an ABO/Rh (or even just ABO). In which case the test's negative QC would include that done for the forward typing. So that CFR 493.1256 (d) (3) (ii) would be satisfied.
Scott
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If at all possible, they would have to consult with our pathologist. Then beyond that, the physician in charge of the case would have to provide documentation that it is an emergent situation and that they are aware that they are transfusing incompatible product.
Having said that, it seems like it would be a really bad idea. Giving A plasma to an unknown is one thing, but O plasma?
Scott
Auto-anti-D?
in Case Studies
Posted
1) The original antibody ID matched an anti-D, as did the eluate.
2) Just one source for anti-D testing. Its a poly-monoclonal blend.
and...
We are pretty sure the gentleman has NOT had any Rh immune globulin.
Genomic testing is, indeed in process, as we have sent the specimen to our reference lab.
The forward reaction with anti-D was a strong and clear 4+. A partial or weak D is unlikely.
The rest is being processed at our reference lab this week. I will post results here...
Scott