Annadele

Oh! By "second piece," I mean another full bag of platelets collected by pheresis from the same donor. Sometimes such a significant amount of platelets are collected that we get up to three full bags all from the same donation. These have the same unit number with a different "part" number.

Does anyone know what the average specific gravity of packed red cells washed with 0.9% saline is? We calculate volume based on weight in grams and specific gravity. I'm about to start a method comparison between our cell washer and an OR's cell washer. Pre and post-volume is one of the parameters we're tracking but I can't seem to find a mention of the specific gravity of washed blood in the Technical manual. Annadele

We use Verax testing to extend the expiration time of our platelets expiring at midnight. Platelets that test Verax negative can be transfused before 4 am rather than tossed at midnight. Our workload is such that Verax testing each individual platelet before issue would be prohibitive. The ABC newsletter from July included an interesting article with some preliminary results from hospitals using PGD tests. One study found 7 positives via PGD in 70,561 platelets tested. Two others in smaller hospitals both found no positives out of a few thousand platelets tested - both of these discontinued its use as a point-of-issue screening for all platelets.

We request a current platelet count prior to and within one hour post platelet transfusion but the policy is only "enforced" (and I use that in the most mild sense) if a second platelet is requested after the first. We have a collection of "Please take platelet count within one hour post-transfusion" stickers that a technologist can put on a bag of platelets before dispense to help remind the nurse. As others have mentioned, this is mostly just for the sake of being able to document counts in case the patient seems to become refractory. It's nice to be able to give a patient a second piece of a unit that they experienced a particularly good "bump" for so the information can be useful. We don't ask for post-transfusion Fibrinogen for cryo or coags for FPP as far as I know but one of our techs does collect data on those values prior to cryo/FFP transfusion (and other reasons for transfusion). I've definitely found it helpful from the perspective of inventory management to check fibrinogen, platelet counts, coags, etc. before transfusion of components if the product that I'm about to prepare has a 24-hour-or-less outdate. Particularly in late summer after new residents arrive, it seems as though it's not uncommon for us to get orders for products that are later cancelled or delayed.

Our lab is devoid of radio - in fact no speakers are enabled on our computers at all. Since I'm a weekender and 2nd-shifter, I've often longed for some public radio in the background - particularly during inventory. Sensory deprivation has at least as much of a negative affect on concentration as excessive noise, IMHO. But you have to do what works for the majority of your coworkers and it's a good thing to have an agreed-upon policy either way to prevent friction.

I've been meaning to ask you what anti-DOLG is since you shared those regional meeting minutes with me (I couldn't find a reference for it anywhere!)!! Thanks! Annadele -- If all else fails, such as with our anti-DOLG (anti-Do8), we send it to the International Blood Group Reference Laboratory in Filton. THe fact that we couldn't identify the anti-DOLG was not surprising though, as it was a completely novel antibody within the Dombrock Blood Group System.

If anyone finds a study about sending platelets through the pneumatic tube system, I'd also love to read it! Annadele

In our Transfusion Service laboratory (in a 900+ bed hospital), new staff are trained for 2-3 months. It's my understanding that the exact amount of time varies depending on their level of experience and whether or not they've rotated through the laboratory as a student. (Many of the new hires here do.) I love the suggestion to incorporate competency testing with wet samples into training, preferably tested in parallel by an experienced technologist. This aspect of training will help the new employee gain confidence as well as help you gain confidence in their abilities or highlight areas where their training can use some reinforcement. I also recommend showing new hires your lab's deviations from the past year at the end of training (as a way to gives them a heads up of where things go wrong most often) and suggesting that they read through the immunohem work-ups of others on a weekly basis (or, even better, incorporating them into a rounding scheme where serology seniors share more complicated work-ups and their resolution). Above all, cultivate an atmosphere in your laboratory where everyone is a teacher and encourage your techs to develop teaching as a skill! For your senior technologists and managers, teaching ability and enthusiasm for the profession should be a CRUCIAL consideration when it comes to advancement. In a profession that more and more graduates seem to be using as a way station, the average technologist will have less and less experience over time. The only way to ensure that patients don't suffer for it is to beef up your training program. And conveying enthusiasm to a new hire not only makes them more likely to stay, it also instills pride in their profession that can encourage them to stay techs!

We were able to use the Verax PGD Test to extend the expiration time of an expiring platelet by four hours. Since our bone marrow transplant patients often have platelets ordered just after midnight, this often means the difference between "wasting" a platelet and using it and helps preserve our inventory when low. Annadele

Thank you both! No clear explanation still today! I should have mentioned before that this patient was also at one point found to have PNH (though his most recent PNH screen was negative), has received an out of group bone marrow transplant (historically A pos with an O pos BMTS) and receives washed products (I'm assuming by physician request because of the PNH history to wash complement out of donor blood?). Though his bmts hasn't fully engrafted, our automated instrument typed him as a clean O pos. Mixed field was observed during a tube ABORh recheck however. His caretakers seem to be focusing on this as a possible culprit since he IS producing anti-A and is still producing some A pos cells. I took a look at the eluate today and two C positive cells were unreactive with the eluate. One was an RzR2 but the other was an r'r. All of the Fya positive cells were reactive. A work-up from early in May had some stray reactions that were attributed to an HTLA (but it only titered to 4) but it hasn't demonstrated in work-ups since then. Their bilirubin and LDH ARE slightly elevated but not enough to raise huge flags (particularly considering the warm auto). Both of the units transfused on the 24th were crossmatch incompatible yesterday with slightly positive reactions. Since it was both of them, I'm guessing that that sorta rules out the possibility of a low incidence. We don't have a pre-transfusion sample anymore unfortunately - our oldest samples are from the 8th and the patient was transfused here for the first time on the 7th. According to the physician, the patient hasn't been seen elsewhere.

About an hour ago we received a call about a possible delayed HTR. The patient has slightly elevated LDH as well as the following: DAT: AHG + IgG + C3 - (check cells checked) Eluate: Positive for anti-C and anti-Fya The patient has a history of several antibodies, anti-C and anti-Fya and a nonspecific WAIHA among them. They've received several transfusions in the past month and received a particularly horrible bump one time in particular. We've antigen-typed all of the transfused units' segs and all are antigen negative for C and Fya. Thoughts?

In a time where fewer and fewer techs seem to be remaining in the field for more than a few years, it can make a big difference to patients to respond to a tech force that is getting younger by strengthening training programs including case studies, taking steps to motivate new employees positively, and beefing up continuing education. Even if you don't have case studies developed, you can hand a trainee a stack of your work-ups from the past month or so. A team is only as strong as its weakest link and the patient is ultimately better off if everyone in the laboratory feels responsible for the professional development and training of its current "weak" links.

Poll: Does your Transfusion Service have a program resembling rounds? How does it work and do you have a mechanism in place for helping all shifts benefit from it? We have a solid continuing education program thanks to a great coordinator but don't have something like grand rounds. I'm thinking about suggesting it as a way to help everyone in the lab learn from unusual, extraordinary, less common cases or even deviations (especially new technologists). We have about 35 technologists in our Transfusion Service over three shifts and since we're located near a couple of universities with CLS programs, technologist turnover seems relatively high. There are four new techs starting this summer. I trained in a micro lab that had daily grand rounds - in that case it was set up to benefit medical residents - and I think that it helped a great deal to contribute to a team-oriented, educational work atmosphere in which everyone was an equal participant. In that case, an MD led the grand rounds through each "station" with each technologist in micro who would present any interesting cases from that day (if they had any). Afterwards, the same MD would quiz the group rotating through with questions about that bug (or similar bugs) usually present - both medically and in the lab. They also had weekly rounds just for pediatric cases in which the residents reviewed all of the cases from that week as a group with their attendings. They invited any micro technologists who wanted to attend who brought up the physical plates as well. (Credit here should be granted to the attendings who clearly felt it was important for the residents to have at least a general understanding of culture.) As you can imagine, both forms of rounds really opened up an excellent line of communication between the residents, attendings, and technologists. All participants seemed to have a good understanding of the other side's role in patient care. And I have no doubt that their patients benefit from that kind of open communication. The laboratory itself rarely has openings but when they do, graduating technologists who have trained there are quick to snap them up and I'm sure that that is thanks at least in part to rounding. I'm not sure that something similar involving direct patient caretakers is really possible in Transfusion where many areas of the hospital are "frequent flyers" but perhaps a lab-centered format that just involved our senior technologists and/or medical directors would still have a great impact as far as expanding communication is concerned. I'd love to hear from those of you who currently use similar programs in your place of work - how it's structured and what kind of impact you think that it's had.

Hi All! I just wanted to let you know that the final conclusion was that the reactions might be due to a possible HTLA. The HTLA titer was rather low for an HTLA but no other explanation was found. She got two least incompatible units - no reactions after transfusion that we know of.

Thanks Malcolm! We opted to go ahead and crossmatch them for a couple of units (they're supposed to be transfused on Monday) ....and both units were incompatible. First shift consulted with our analytical supervisor who advised us to do a cold screen and try prewarming if it's positive. Annadele

Hi All! I'm looking for general ideas involving in a case from this weekend that none of our resident immuno gurus have reviewed yet. A selected cell appears to give me p values for an anti-s. The plasma doesn't react with any of the heterozygous cells but reacts at + or 1+ with all of the S-s+ cells chosen. The patient has multiple other antibodies. The patient has been antigen typed via Bioarray and is S-s+. They're white so Dantu (with a weaker s expression that could therefore possibly produce an anti-s isn't likely?). The Bioarray apparently would flag you if the patient is U-. The patient's DAT is negative by AHG including a five minute incubation. Let me know if any more information would be helpful!

Or it might be better to use an r'r with C but no D since anti-G reacts with all C positive cells and G expression is greater on D negative cells?

We require only an historical type (with recheck performed on the same sample) in order to issue type-specific plasma or platelets.

I haven't done this before AND am a newbie. But if I had to pick one, I'd choose an R1R1 - that way both the D and C ags are strongly expressed. According to my handy text, the RBCs used for each titration should be of the same genotype and from the same donor, of the same concentration, and the same storage time. Has anti-G been implicated in HDN? How do you differentiate between an anti-G and a true anti-D plus anti-C? (Or is anti-G just presummed in cases where the patient hasn't been exposed to the C ag but appears to have anti-D,C anyway?)

We just recently got a StatSpin Express 3 which is super quiet and fast as well. It's so quiet in fact that at first there was a rumor circulating that it doesn't need to be balanced.

Hi again! I'm back at work today. The patient was a heart/lung recipient. I'm not sure how long ago they received the transplant - only that they're receiving IVIG once a week.

Thanks! I think that he was a transplant patient. I don't go back into work until Thursday to find out for sure. He's receiving IVIG once a week but this is the first work up that it's caused a discrepancy in. Annadele

Hi All! I had an ABO discrepancy on the bench last evening that I'd like to pick your brains about. The patient typed A positive with a ? in the backtype with A cells by solid phase on a Galileo. By tube, the patient typed A positive with a 1+ reaction in the backtype with A1 cells that were in-date. Initially, I tested with A2 cells and got a positive 2+ reaction so abandoned my anti-A1 theory and proceeded to perform a cold screen. After a 15 minute incubation at room temperature, there was no agglutination with any screening cells, cord cells, OR A2 cells but a 1+ reaction with A1 cells and a 1+ reaction in the auto control. I performed a DAT because of the positive autocontrol which was positive by AHG (2+) and IgG (1+) but negative with complement. After these results, I realized that I hadn't let the A2 reagent cells get to room temperature before I'd used them so my initial results with the A2 cells were likely invalid. The room temperature A2 cells were negative at initial spin. (Mental note to always let reagent cells come to room temperature.) Back on a possible anti-A1 path, I tested the patient's cells with anti-Al lectin. It was positive with a 4+ reaction. The patient had been receiving transfusions with type A positive blood here and there but not enough to make me think that that could invalidate the A1 typing results. I would think that a transfusion here or there might yield a mixed field or a weak A1 typing? I then tried to test with additional A1 cells to investigate further but, even after a 10 minute incubation and a view under a microscope, neither of my out-of-date A1 reagent cells yielded a positive reaction. I also tried testing with some unit cells but it was also negative. I prepared an eluate before my shift ended that another tech tested with all three A1 cells and screening cells. Her results were + with all three A1 cells. The patient has a history of having received IVIG about a week ago. Can we close the case by assuming that the backtype discrepancy is due to ABO isoagglutinins in the IVIG? Are there other possibilities to investigate? Should the patient receive O positive transfusions if they are ordered and is this because the (supposed) passive anti-A1 was found in the eluate? (If the eluate had been negative, would we give XM compatible A pos?)

As a new technologist, I've often lamented that the best I can possibly hope for is to be as good at most of the tasks I perform every day as a machine would be. I think utilizing the technology that you have available when/if you can frees up technologists to focus on tasks that aren't as routine and prevents that mind-numbing that might lead to errors. Annadele

Hi All! We also use OR schedules. Second shift is responsible for printing them and for filling the orders. It seems as though about half have a TS drawn during an outpatient appointment prior to surgery while others don't have one drawn until they come to the hospital that day. We have so many surgeries scheduled during the week that I can't imagine filling those orders as they come in! I'm not sure how long we keep them but I know that it's longer than a day - my guess would be about a week. Annadele