saralm88

We are a large academic medical center / L1 adult and peds trauma center.
We stock 4 helicopters, at least 4 county EMS units (with more onboarding)  (all 2 Opos WB units each)  We also have an Adult ED refrigerator where we try to keep a minimum of 8 WB along with a few RBC's and Liquid plasma units.  We also stock 2 units O neg WB in our Peds ED refrigerator.
Our Massive Transfusion protocols allow us to transfuse up to 10 O pos WB to anyone >/= 16 years of age.  
We have a standing order for WB with our supplier for 40 units per week.  

Building Soft to join with Epic at the moment.  I have the same issues mentioned above.  The traceability work arounds are a huge issue for us.  Epic allows for "Other collector" and it will time out and autofill the collect time as the current time instead of forcing an entered result that will match the written time on the tube.  I feel comfortable with the WBIT being minimize, but since the tracking to phleb ID and correct collect time is an issue I am requiring a second tube for compliance sake.  We are dropping blood bands with the Soft go live because the security features added to BPAM are leaps beyond what we currently have.  Blood bands at current have only caused problems and patient delays,  never stopped a patient ID issue.

UNOS has guidelines on off-type kidney transplants.  We were using the UNOS protocol for DTT treated iso-titers, but have transitioned to running IgG and IgM iso-titers on our NEO Iris.
https://community.asn-online.org/blogs/mark-lerman/2018/07/09/weekly-rewind-abo-incompatible-kidney-transplant-r
https://optn.transplant.hrsa.gov/media/2347/mac_guidance_201712.pdf
 

Yes, that is an electronic ID system. Just make sure that you write your specimen collection procedure very carefully.  The phleb should still be verbally IDing the patient and comparing that with the patient armband (full name, birthdate) and matching the Rover info with the patient armband. The procedure should also state that the label will be printed at bedside and the tube labeled at bedside. You will also need policy for what to do if the phleb is unable to scan the armband (Rover not working, emergency specimen collection and no armband present, OP collection if Rover not used for patient ID, etc.). There may be some specimens that can't be collected under the electronic ID process, which would require another process (2nd specimen collected or Blood Bank armband or ???). 

Quick update on my case: I submitted a further blood test, as requested by the lab. Received the results nearly 3 weeks later. Turns out that no alloantibodies were identified in the samples. The comment from the lab says: 'One reaction of no apparent specificity was detected by the following techniques Bio-Rad IAT. No alloantibodies were identified by the following techniques: Bio-Rad Enzyme IAT BioVue IAT. Antibody and clinical significance: This antibody is unlikely to cause haemolytic disease of the fetus and newborn. Repeat sampling: No further samples are required for reassessment in this pregnancy.
So it looks like the initial test, that I was so worried about, was a 'False positive' so all good in the end. Most grateful for Malcolm's helpful responses, I did learn a lot in the process. 
 

I could "listen" to Malcolm explain stuff all day!!  

Awesome responses as usual Sir!

Thanks ELondon.
Could I just say again, even if the Reference Laboratory does detect an antibody (or more than one, come to that), it is not a particularly abnormal thing in pregnancy, but it does not mean for one minute that the pregnancy will be affected; Mother Nature has seen to that.
There is another Blood Group System named Lewis.  The antigens within this system are soluble in the plasma part of your blood, and are adsorbed onto the red cells from the plasma (they are not intrinsic to the red cell membrane).  During pregnancy, the concentration of plasma lipoproteins (fatty proteins in the plasma) can increase enormously (about four-fold).  These plasma lipoproteins "mop up" the soluble Lewis antigens, and a pregnant woman, who would normally be, for example, Le(a-b+), can become Le(a-b-), and may even, temporarily, produce antibodies against the Lewis antigens (an individual hardly ever produces antibodies against an antigen that they express - but strange things happen in pregnancy!).  In addition, ALL babies are born as Le(a-b-), so any Lewis antigens Mum produces will NOT affect the baby!
There are many, many other antibody specificities that will not affect the pregnancy at all.
Now, I should say two things.  Firstly, I cannot say, from a distance, what is the antibody in your plasma (that can only be done by the laboratories at the Hospital and the Reference Laboratory, but it does not sound at all serious).  Secondly, i am what is called a Biomedical Scientist, not a doctor, and so I am, by Law, not allowed to diagnose (as far as I know, neither is the midwife), and this is why I am so glad that you are going to see an Obstetrician, who, I hope, will be able to reassure you even more.
Mean while, sleep easier, and enjoy your pregnancy!

PLEASE do not worry.  Your midwife is COMPLETELY wrong, and really should not comment about something she patently does NOT understand, and about which she has a pitiful amount of knowledge.  She should never have answered your questions with her lack of knowledge, but should have left it to your Obstetrician.
I note that you are a fellow "Brit"!
Within the British population, the percentage of people who have the R1R1 type (which is a type within the Rh Blood Group System) is 16%.  Also within the British population, the K- type (which is part of the Kell Blood Group System) is 91%.  What that means is that 91% of 16% of the British population is R1R1, K-, or, give or take, a few decimal points, 15% of the British population (about an eighth of the British population).  On Friday, 19th October 2018, the British population was measured as 66,690,116!  Let's call that 16.5 million in round numbers.  This means that, give or take, 9, 975, 000 in Britain are R1R1, K-.  Now, admittedly, your midwife will only be looking after women, but, even then, that means 4, 987, 500 women will have the same Rh type and K type as you!  How your midwife has only come across your "rare" type four other times in her career, is beyond belief (and I genuinely mean BEYOND belief), unless, as I say, her knowledge of blood groups and blood group serology is incredibly poor, and I repeat, she should NEVER have worried you like this.  Just in case you think that I do not know what I am talking about, I have worked in the field of blood transfusion/blood group serology for 43 years, have been an internationally invited lecturer and am the Chief Examiner in Transfusion Science for the Institute of Biomedical Science in the UK, and am a co-author of the British Society of Haematology's Guidelines for Blood Grouping and Antibody Testing in Pregnancy.  I don't write that to "blow my own trumpet", as it were, but to try to reassure you that I actually do know what I am talking about.
I should warn you that "consulting Dr Google" is equally as useless as listening to your midwife.
You should really relax.  YES, it is possible for you to produce red cell antibodies during your first pregnancy, but it is INCREDIBLY RARE.  It is even more rare for such an antibody to cause any problems in a first pregnancy.
I notice that the report from the Blood Bank was that they detected WEAK reactions with 26 of 30 panel cells, but they could not identify a specificity.  They have requested three further samples of blood to send to the Reference Laboratory.  Again, to give you some comfort, I hope, I ran a Reference Laboratory in London for 16 years before I retired in 2016, and we saw, quite literally hundreds of cases like yours.
For a red cell antibody to cause any problems within you pregnancy, it would have to have a titre of 32 or above (this means that it would still be detectable when it has been diluted THIRTY TWO times).  I can assure you that the mere fact that the Blood Bank reports weak reactions means that there is ZERO chance that the titre will be 32 or above.  If a Hospital Blood Bank, however big or famous the hospital may be, cannot identify an antibody, it is almost universal practice that samples will be sent to a Reference Laboratory for further testing - AGAIN, DO NOT WORRY ABOUT THIS.
There are many, many red cell antibodies that are clinically insignificant, both in terms of transfusion reactions and haemolytic disease of the foetus and newborn (which is what your midwife has left you worried about).
I KNOW it is difficult, but PLEASE do not worry.  PLEASE take no notice whatsoever of your midwife on this matter (I am sure she is an excellent midwife, but she is patently no expert in the field of blood groups), but DO talk to your Obstetrician, who, I hope, will have talked to your hospital's Haematology Consultant, who, in turn, will have spoken to the Consultant in Charge of the Reference Laboratory, and I am sure that they will echo my opinion that there is NOTHING to worry about.
Oh, and lastly, I am R1R1, K- myself!!!!!!!!!!!!!

I did allo-adsorptions on eluates for quite a while and never once detected anything in the adsorbed eluate.  My own experience suggests that it is a waste of time and resources, but others may disagree.

I agree with Malcom - not much value, if any. I, too, have done many such noninformative adsorptions.
In a recently-transfused patient, there is perhaps a very remote chance that (allo)adsorptions on an eluate would reveal a "only on the cells, not in the serum yet" newly formed antibody. This might be important if the clinicians suspect faster-than-normal red cell loss, but it would be very difficult to differentiate from the typical increased red cell demise seen in patients with warm autoantibodies.

Somewhere, in Patrick Mollison's work, cited in Blood Transfusion in Clinical Medicine, he mentions that IgG ABO antibodies are more clinically significant in solid organ transplants than are IgM (if I remember correctly, he specifically mentioned renal transplants), but I cannot cite the exact paper off the top of my head (I will see if I can find the reference).

As a result, whenever we were dealing with a renal transplant that crosses the ABO barrier, we almost performed an IgM and an a separate IgG titre.  Whether this is now considered to be necessary, I will leave to other people to discuss!

There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong.  See below for the reasoning and published data.  We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data.
BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1
Letters
Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data.
In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5
We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients,
such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply.
Competing interests: None declared.
1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250
2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995
3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A.
4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246
5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
LETTERS

We did this 3 years ago. We did a minimal validation. The reagents were all the same so you're only really validating the mechanical components of the new analyzer. Therefore, we did just enough to show that the new machines got the same results as the old in regards to blood types, antibody screens (no identifications), DAT, and crossmatches. I think we did 10 specimens of each representing each blood type.

I have no experience in determining what is appropriate so take the following opinion with salt. It seems reasonable to save and freeze samples tested on your current Echos that include negative and a variety of positives . Then thaw and test on the new instruments and compare results.  I mean this process is used to compare prenatal titers. I would suggest 40 samples as 30 is regarded as the minimum number that permits statistical analysis (if memory serves). 

Lies, damned lies, and statistics.
You've asked the question that has plagued my small brain for almost three decades.  How many is enough - the question cannot be answered to everyone's satisfaction.  Some will tell you to do more, others will tell you your plan is overkill.
Everything is a risk; you need to use sound judgment and work with your CLIA director to make sure they are satisfied with your plan.
When we moved to a new computer system, we had millions of records.  I chose to use statistics.  We fully validated 384 randomly selected records - lots of sites to determine this number.  This took a tremendous effort to complete.  As the years went on and we "simply" upgraded to a newer version, we had a solid history of working with, and validating, the software so we eased up a bit on our plan.
These are brand new instruments, albeit with the same methodology.  You need to perform a validation that will ensure each new device performs as expected.
I always started with the vendor; they almost always offer a suggested plan.

yan xia, there are two mutations present.
The first, RHD 4.0/RHD DAR3.1.  This will lead to the expression of a Partial/Weak D.

The second mutation is a hybrid of the RHD and RHCE gene, with exons four to seven of the RHD gene being replaced, or substituted, by exons four to seven of the RHCE gene.

I hope this helps a little.

In my case, working in a Reference Laboratory, we usually have to work on the sample that is sent, which is usually the cord.

We always work up a positive DAT with elution and antibody ID.
 

In my opinion, you can run an antibody screen on the last wash instead of a full panel.  Of course if the screen is positive, you'd want to run a full panel.  I have never known the last wash screen to be positive.

so so helpful!!  thank you sonya!!!

I've attached our policies for preparing aliquots in general and our platelet policy.  Hope this helps.  Oh, we decided all aliquots in syringes expire 4 hours after being made to make it easier for both blood bank and nursing staff to remember.  We used to let the RBC and FFP syringes expire in 24 hours but nursing in particular would think all syringes expire 24 hours and we wasted a lot of syringe aliquots until I changed it.
BBI0015 Preparation of Aliquots.04.03.2020.doc BBI0017 Platelets 04.03.2020.doc

We require a second sample for ABO confirmation if the patient's initial type is other than group O before we can issue blood. It is ordered separately, so I believe the patient is billed for it.

We require a second speicmen be drawn if there is no history and if the current sample type is not O. We will use a specimen in the lab that was drawn at a different time (ex. CBC drawn earlier in the day). We do not currently charge for the test.

Get to know your staff, but remember that you are not there to be their buddy.