kirkaw

Under NO circumstances would I process an unlabeled sample.  It is far too dangerous, whether the standards allow it or whether they don't.

I wouldn't discard out of hand. We had a similar situation where we were temporarily storing frozen products in a freezer that did not have continuous monitoring and a tech reported a temp of -17C. Our supervisor submitted a biologic deviation report to CBER/FDA and we were able to use the products, which were obviously still frozen.
 
I would quarantine everything and check into this with the FDA -- while your products were a bit warmer than ours I would say that -12C should still be pretty frozen.  I believe that we quarantined until the report was reviewed and the products were released. Seems a shame to toss everything without looking into it.

In my opinion,knowledge is power. If you have access to a Technical Manual or some other Immunohematology-type text book, just start reading. Sometimes, lack of knowledge in theory and hamper your critical decision making skills, as maybe happened with your anti-M. Also, if you get a chance, spend some time on day shift and see how those folks handle antibodies and emergencies. Granted, it will be different on evening shift, but at least you can observe their thought processes and process flow. 
 
I am a supervisor at a non-trauma center community hospital and my techs call me at night, on weekends and when I'm on vacation. I'm more knowledgeable on day to day stuff than our pathologist. But I also TALK to people and see if there's any learning opportunity that they need to make them more confident, whether that's doing an in-service with me, having me work with them for part of a shift or having them join us on day shift. It's a coordinating effort but well worth it. I want my techs to be confident and one of the better ways to do that is teach them where to find the information they need and how to make good decisions.

In my opinion,knowledge is power. If you have access to a Technical Manual or some other Immunohematology-type text book, just start reading. Sometimes, lack of knowledge in theory and hamper your critical decision making skills, as maybe happened with your anti-M. Also, if you get a chance, spend some time on day shift and see how those folks handle antibodies and emergencies. Granted, it will be different on evening shift, but at least you can observe their thought processes and process flow. 
 
I am a supervisor at a non-trauma center community hospital and my techs call me at night, on weekends and when I'm on vacation. I'm more knowledgeable on day to day stuff than our pathologist. But I also TALK to people and see if there's any learning opportunity that they need to make them more confident, whether that's doing an in-service with me, having me work with them for part of a shift or having them join us on day shift. It's a coordinating effort but well worth it. I want my techs to be confident and one of the better ways to do that is teach them where to find the information they need and how to make good decisions.

It depends on the antibody and we know they are all not textbook perfect sometimes. Es can be naturally occurring. Manual gel vs Provue should theoretically be identical (same reagents) but I think the camera reading the reactions on Provue, is perhaps better than the human eye?
 
Perhaps the card incubated slightly longer on the Provue and antibody just started to be picked up. I only see this every once in awhile. Most repeats we do are fully negative on screen and panel (total of 14 cells tested).
 
Since we really only detected it in Ficin, it could have gone completely missed but I'm glad it didn't.
-Colleen

At minimum we do a DAT in addition to visual inspection for hemolysis on the post transfusion sample but I would caution that unless the post transfusion specimen is collected right away- hemolysis can be missed (I have personally seen it happen). 

I call that the "baptism of fire".  Just remember that experience is the best teacher.  If you find yourself in such a scenario where you do not feel comfortable or need help with a decision, is there a supervisor or on call person that you can reach out to?  As a newbie there really should be some kind of support for you in these situations. 
 
Just a battle story to share....  we are not a trauma center either and a while ago when I was new,  we had a patient that came in as a trauma and they wanted emergency release.   Blood was issued and then we found out the patient had multiple antibodies.  I believe that one was a Kidd.  Of course, the units that the patient was given were incompatible.  Because "universal donor" is really kind of a misnomer in scenarios like this. I had obviously never been in a situation like this.    I learned a few things after that incident- the first is that we aren't a trauma center. Almost always the patients that we get are not stable enough to go to another hospital which leads me to my next tidbit... if the patient is bleeding so bad that they cannot wait for crossmatching and antigen typing- the immediate risk to the patient of not getting blood is greater than a potential transfusion reaction.  They just need the oxygen. 
 
Since that time we have had this happen on occasion and while it still makes me nervous it isn't that drop in the pit of my stomach anymore.  Don't be discouraged, you will gain the knowledge over time to be confident in your decisions! 

I understand your concern and would first want to identify a cold by running appropriate tests before jumping right to prewarm and assuming that because reactions went away that it was due to a cold.  Many years ago when I was a new supervisor, I observed exactly what you described and was bothered by it.   I reviewed past workups that were identified as cold abs and found that many were really wishy washy anti M's.   I did find one Fya  that was reacting sporadically with only double dose cells.   The way they performed antibody id was quickly changed to stop the practice of prewarming away unexplained reactions. 

I have taught through the years that one should "never" assume something is a Cold Agglutinin unless they prove it (with a cold panel; i.e. Screening Cells, Auto, Cord and whatever Reverse Cells the patient is Negative for). I even have a story of a place with a similar protocol to what you discuss (though much worse).
When I was a Reference Lab Supervisor, we received a "very" hemolyzed specimen on a patient who had a hemolytic transfusion reaction. The Hospital sent their panel work. They did run a panel; and it was a perfect pattern of an Anti-E; but their Policy (and I can only hope they misunderstood it) was that they should try to perwarm it away and if it went away, it was not significant. A week later, we received another hemolyzed specimen from the same Hospital (different patient). This time the patient had a perfect E and c; but again, they managed to prewarm them away (which is another pet peeve of mine.....trust me, I have seen many clinically significant antibodies prewarmed away...by good Techs.; even in large, prestigious Medical Centers....so I tend to be very anti-prewarm except in the right hands). Anyway, I called their Medical Director and told her they needed to "cease and desist" with prewarming before they killed someone (not to mention, teach their Techs. how to perform basic Antibody ID).
Your Policy is not "that" bad in that your supervisor is saying you have first ruled-out major alloantibodies. But let me tell you another problem (sorry to belabor the point). If you use GEL, know that I have seen "many" instances of Kidd group antibodies that not only do not react with any heterozygous cells; but do not even react with "all" homozygous cells. So just saying you ruled everything out, doesn't necessarily mean you did. Not only have I seen that in Hospitals I have worked in; but also in work-ups sent to us at the Reference Lab from Hospitals that used GEL but did not know of this potential problem.
So, I have also taught through the years that even when you think you have ruled everything out, you need to look at your positive reactions and see "what do all of those cells have in common?" You might run into some surprises.
Brenda

This topic comes up here from time to time.  The issue here (to me anyway) is not whether there is a specific QA standard for AB panels in BB, but whether or not the GENERAL rule about following manufacturer's instructions applies.  Because every package insert I have ever seen says something about periodic QC for AB panels, (as Laurie points out, above).
 
I would be interested to know if anyone else has had a problem with this.  We are FDA and JCAHO inspected and it has never come up here.
 
Scott

The centrifuge radius is probably a bit different so different RPMs gives the same g force.  I had to rewrite procedures and forms to accommodate our different RPMs at our different sites.

Thanks for the pics, ours is very old and has the tube wells.  Shame on Ortho for not thinking through how to take this temp easily.  BTW, nice job on rigging a thermometer.
 
You should patent this for use is US

Primarily an MDs order
other considerations
     immunocompromised pt
     directed donors - genetically related
     Premature infants <1200g at birth (should not happen at my place but it is in my policy)
     HLA matched plt recipient
 
I know some large teaching institutions which irradiate for all patients

I am seeing more of these types of citations when inspectors who worked in Chem and Hemo want to apply all of these regs to BB and Micro. Some of them should be, and some just don't make sense. As David stated above, we're not looking for BB QC results to fit into a narrow range of values, but do they work as expected or not. And they always do.
Just like the correlation of methods: if you have 2 CBC anaylyzers, you need to correlate that the results from either analyzer are very close...makes perfect sense. Comparing tube testing with solid phase or gel is like apples and oranges; they don't always correlate so you're just proving what we already know...that if you have an Anti-K reacting 1+ in gel or solid phase, it will most likely be negative in tube testing.

Kirkaw - I kind of like that every regent in use is tested - just the opposite of CAP which says only one bottle of a lot in use needs to be qc'd each day.  You can have racks out all day and night and never qc those reagents if you follow the CAP guidelines.

I don't think there's a question about whether it's per antigen or per unit, or even if you have to test more than the patient is ordered for due to positives - we can all agree there's enough information out there that says that's completely fine.
 
The troublesome situation is when blood is typed/ordered antigen-negative from the blood supplier and then not used on that patient but subsequently used for a different patient.
 
The appropriate practice described by my "first line" billing compliance individual filled me with terror because it was so convoluted. I'm going to climb a bit higher up the chain and find out their perspective. Have others spoken with their billing compliance people (specifically ones who are familiar with lab/blood bank)?

I consider all of the following to be different methods: manual tube, manual gel,PEG, enzyme, solid-phase, ProVue, Galileo, Echo, Tango, Immune Rosetting Test kits, Kleihauer-Betke Staining kits.

Was antigen typing done on the patient for K and C at the time the anti-e was identified? When was the patient last transfused? Can you antigen type them now?

I can find no standard that requires remote monitoring of temp alarms. Just that the temp needs to be maintained 24/7.

We do run IgG DAT's on ProVue for Cord Blood testing.  We make our own positive (O Pos donor cells coated with IgG) and negative controls since there are no manufctured controls for this.  It seems like this is more in the way of QC'ing the method since Antibody Screen QC QC's the IgG reactivity of the Gel cards.

Anything will be better than TraceSafe... I use it too and it is awful

Was antigen typing done on the patient for K and C at the time the anti-e was identified? When was the patient last transfused? Can you antigen type them now?

A few random observations:
I think that the current consensus is to transfuse less rather than more. The old "if you only need one unit..." dogma resulted in doctors ordering 2 units instead of one, when the point was that they should be ordering none in situations where only one is ordered. Nowadays, triggers re lower, and we are seeing alot more single unit orders (as opposed to 2 unit) but I think this is a step in the right direction.
Patients apparently do indeed do very well with lower transfusion triggers. There have been studies that show that in many cases, they can do better or as well as patients who have been transfused. Then there are the risks associated with any transfusion: TACO, TRALI, not to mention those annoying febrile reactions.
For patients that need to be transfused regardless of the above: I believe most physicians give blood empirically. By that I mean, if the trigger is reached, you give enough blood or whatever to correct the problem. Only in patients with an ongoing "acute" hematological issue (like a GI bleed, DIC, coumadin reversal, whatever) would you need to check the "effect" of the transfusion.
Having said all that I, too, have heard that hemodynamically, things don't even out for about 24 hours after a transfusion. As noted by others above, a patient's therapy and condition (lasix, other perfusions, active bleeds, etc. etc.) is going to make even that iffy as to being able to predict the precise effect of the transfused product.
Scott

I'm sorry Whitney Poplin, but I disagree with your post.  Just because the antibody screen is currently negative does not automatically rule out anti-C and anti-K, for the very reason that it does not rule out the known anti-e; that is also not detectable at present.  From the logic of your post, you could, therefore, also rule out the known anti-e, and give e+ units.
 
No, the anti-C and anti-K should have been ruled out properly in the first place in my opinion.
 
Now, because this was not done, you would have to honour the potential anti-C and anti-K, in case either of these "phantom" antibodies cause a transfusion reaction, due to an anamnestic responce - and, of course, the same applies for the "real" anti-e.

What would you do today for a patient with a positive antibody screen and anti-e is identified, but cannot rule-out C and K?
I think you have to select e-neg, K-neg and C-neg red cells for crossmatch/transfusion regardless of the results of the antibody screen.