SMILLER

Where's the snow?

This is a new one for me (after 30 years!) An ER patient presented recently with a MCV of 107 and low MCH, MCHC. This patient was in house at our hospital just last week, with all normal indices. Called the RN in ER who commented that she is expected to have a very high glucose. Googled it and sure enough, hit a few articles like this; https://www.ncbi.nlm.nih.gov/pubmed/7259094 The patient had a glucose over 1400 g/dl. My question is this: for those of you who are aware of this phenomenon, do you attempt a correction and report that out? Apparently this is a in vitro pj=henomenon related to hyperosmolality when the blood sits in the EDTA tube before processing on the ananlyzer. The "cure" is to do a saline replacement and let it sit a bit. Thanks, Scott

We start with O Negs but after 4 - 6 units, we would switch to O pos for those patients in question in order to have the remaining O Negs on hand for women of childbearing age, should one show up. Note also that our nearby blood supplier can have more RBCs to us within about 45 minutes. We are a level 2 trauma center. Scott

The difference between a BB armband and having only a hospital armband is significant only if the Lab is responsible for specimens drawn under the BB armband. One needs a strict policy regarding the use of BB armbands to make them effective for avoiding things like mis-labeling and lost armbands. Scott

Pre-, at 15 minutes (patient is monitored for first 15 mins), every hour thereafter, one-hour post-. I think that's pretty standard. In the US it may all be by the book as far as regulations. Scott

Has anyone else ever noted these? These crystals appear with Wright-Giemsa stain as greenish aggregates in neutrophils. They are often associated with severe necotizing liver disease. Here is one reference but there are others on the net: https://www.ascls.org/communication/ascls-today/320-ascls-today-volume-32-number-4/431-a-case-of-blue-green-neutrophil-inclusions In the articles I've looked at, they may only appear in 1-2% of cases, so they are easy to miss. There are a few good images on the internet if you look for them. I was wondering if anyone else who is aware of these things, routinely reports them if they are noted. Thanks, Scott

LOL! But it occurs to me you may have responded to the mini-cold issue even more often! Scott

Malcolm-- How many times over the years, here on this most excellent internet informational exchange site, have you responded to this particular issue? Scott

I would say that an electron microscope or a telescope would qualify as an optical aid also, but I am pretty sure that is not the intent of Immucor using that term either. The problem with using, say, a high-dry (40x) microscope objective on a specimen from a tube on a slide is that you will have to define how you are going to deal with a false positive. Because as it has been pointed out above, most specimens examined by tilt-tube, be they ABO typings or something involving AHG, will be seen to have at least a few small agglutinated clumps of RBCs if you look at it this closely. To create a procedure for using a scope, one would have to arbitrarily define what can and cannot be ignored under these conditions. Scott

Microscopic check? No. As far as I know, no regulatory agency requires it for DATs. A mixed field reaction is a presumptive positive. We use Ortho reagents, proficiency used to be from CAP, we have since switched to API.

Really, things are going swimmingly over this then? Hurrah! Scott

Thanks Malcolm. Thanksgiving is a little bit more than a bank holiday here today. (Of course, many of us white guys are only thankful because we were not the victims of attempted genocide or kidnapped into slavery) But holy cow! At least we don't have a looming Brexit hanging over our collective heads! Scott

I think of the forward typing as direct test for the patient's blood type, as one is testing for the antigens that define the type (if it works the way it's supposed to with "common" blood types). Unless one has testing problems with unusual ABO subgroups, the forward typing in most cases will be definitive. Having said that, the reverse typing normally serves to sort of "confirm" the ABO of the forward typing, as most people will naturally make antibodies for AB antigens they do not have (not detected in the forward typing). (I agree this is a oversimplification) Anyway, the point being that problems with reverse typings are, I think we can agree, much more likely to be due to an artifact related to the testing conditions (e.g. cold agglutinins), or something other than a peculiar blood type (immunocomprimised patients). The majority of them can be cleared up or accounted for with the various approaches mentioned above, leaving the forward typing as the patient's blood type. Scott

Thanks for your responses. It never occurred to me that the "HI" meant some type of compound antibody--I have never heard of one for H+I, but that is probably what was meant on the old Redcross card. At the time their reference Lab may have had some interference from it if they were looking at IS screen results back in the last century. The patient is A Pos, I suppose they were thinking it was a cold auto-antibody. They no longer have the records. (We were never too worried about her current typings "missing something".) Scott

And back in the days before you retired, you would have given us a typical comprehensive (and enlightening) review of the Lewis system! Scott

Thanks for the reference Malcolm. Nothing like a sixty-year old reference to turn a pathologist's head! Scott

OK, so what is HI then? (besides being insignificant for this patient) Scott

Check your Lab's regulatory/inspection standards regarding blood banking documentation. I am pretty sure that neither JCAHO or CAP allows for only "80% compliance". You may want your director or pathologist to ask those upper-management types whose posterior they pulled that 80% number out of. Scott

Will the other facilities be using HCLL? If so, you will be able to cross reference each others data bases even though they use different patient ID nos. Scott

Is there a difference clinically between a patient with anti-H vs anti-H1? The reason I ask is we have a patient who came in with an old Red Cross card from 1989. There is a copy of a report attached that has "Duffya" and "H1" (or maybe "Hi") on it. The patient has a negative antibody screen. Thanks, Scott

Which seems logical to us who are working on the bench in the Lab. Our reference lab agrees with us. However, our pathologist has other ideas (he seems wary about that "one patient" who produces IgG anti-Lea). What it looks like we are going to be doing in the future is: if there is a history and the current screen is negative, we carry crossmatches through AHG from out regular donor supply. If the Lea is showing up, and the situation is not "emergent', we have to request confirmed Lea negative units from our blood supplier. With this proposed policy, I was also wondering what the likelihood is of inducing a detectable Lea antibody response for the first case, assuming the screen-negative recipient gets a few Lea positive units. Thanks for your responses -Scott

Not too different from what we are currently doing, except when there is only a history of anti-Lewis with a current neg screen, we are required to get Lewis antigen negative units form our blood supplier (they do get annoyed about these types of requests), Scott

We are in the process of re-thinking our approach to how we deal with the Lewis antigens. Between our pathologist, our blood-supplier lab, and our own thoughts on the subject, our BB coordinator is about ready to blow her brains out. There are essentially two situations; one in which a patient is currently making anti-Lewis a (or anti-Lewis b), and one in which the patient has a history of the Lewis antibody in question, but currently has a negative antibody screen. My question then is: what, if anything, do you routinely do in these two situations? Thanks, Scott

I just answered this question. My Score PASS

I just answered this question. My Score PASS