jojo808

My greatest apology for leaving you all hanging. We've been so incredibly busy and short-staffed that I could not even think about anything else but trying to finish up my daily duties. Anyway, seems that the patient also had an impella device that had to be "adjusted" and I believe that corrected the hemolysis. I'm only reading the responses today (2 weeks later)☹️so hats off to you all who thought mechanical causes. I would have not thought that the device would be that far-off to cause the gross hemolysis we saw. We do see slight hemolysis with impella devices but not like this one. I guess never say never. Thank you all for your responses.

My greatest apology for leaving you all hanging. We've been so incredibly busy and short-staffed that I could not even think about anything else but trying to finish up my daily duties. Anyway, seems that the patient also had an impella device that had to be "adjusted" and I believe that corrected the hemolysis. I'm only reading the responses today (2 weeks later)☹️so hats off to you all who thought mechanical causes. I would have not thought that the device would be that far-off to cause the gross hemolysis we saw. We do see slight hemolysis with impella devices but not like this one. I guess never say never. Thank you all for your responses.

My greatest apology for leaving you all hanging. We've been so incredibly busy and short-staffed that I could not even think about anything else but trying to finish up my daily duties. Anyway, seems that the patient also had an impella device that had to be "adjusted" and I believe that corrected the hemolysis. I'm only reading the responses today (2 weeks later)☹️so hats off to you all who thought mechanical causes. I would have not thought that the device would be that far-off to cause the gross hemolysis we saw. We do see slight hemolysis with impella devices but not like this one. I guess never say never. Thank you all for your responses.

My greatest apology for leaving you all hanging. We've been so incredibly busy and short-staffed that I could not even think about anything else but trying to finish up my daily duties. Anyway, seems that the patient also had an impella device that had to be "adjusted" and I believe that corrected the hemolysis. I'm only reading the responses today (2 weeks later)☹️so hats off to you all who thought mechanical causes. I would have not thought that the device would be that far-off to cause the gross hemolysis we saw. We do see slight hemolysis with impella devices but not like this one. I guess never say never. Thank you all for your responses.

Just last month, we had a unit from our supplier labeled as O+ but retype showed that it was AB+.  I personally don't mind re-typing units so that we can do an electronic crossmatch.

Regarding an Anti-M that is showing dosage: 
I understand from reading older posts that an Anti-M is considered clinically significant if reactive at 37C and most would consider transfusing with M negative units in those situations. Would it be correct to say that if your Screening cells did not possess a MM cell for this dosing M to react with, you wouldn't even know you had an antibody even if the anti-M was reactive at 37C? Some posts stated that they do not type units for M but transfuse random units compatible at IAT. In these cases where you are choosing random units, the dosing anti-M would be non-reactive with the MN units and reactive with the MM units. So, you would end up giving "compatible" M positive units (hetero expression) could that cause any problems later?  I also wondered that if your Anti-M is prewarm negative, and you give random IAT compatible units and let's say the units are MN and are "clean" in the crossmatch (prewarm or not) and we are transfusing a unit straight from the (cold) refrigerator ... would that cause binding in vivo? Does it matter if the M is prewarm negative or positive if your policy is to transfuse M negative units anyway?  Sorry for all the questions, I thought I had it down but then someone challenges the process, and it gets you thinking again. Thank you in advance! 

As a general rule, an anti-M that doesn't react with heterozygous cells probably isn't very biologically potent or clinically relevant, so that's my take on that issue.  We honor anti-M antibodies that react at 37 or antiglobulin phase, but many of these probably would not cause significant hemolysis in all likelihood. 

Theoretically, you could have in vivo binding. Practically, I've never seen it happen. We do not type for M antigen and give xm compatible here. 
 

In the UK this problem should not occur, as our BSH (BCSH) Guidelines mandate that our screening cells have homozygous expression of certain antigens, one of which is M.

Ok, a list of 'agree/disagree' items here:
I agree with your supervisor on one plane: Don't write things on documents unless you are instructed to do so. It's very important that things don't 'depend on who is working this shift' ... Blood Banking is a team sport and demands consistency.
I disagree with the 'use a blood warmer only if the cold agglutinin reacts at 37C'. If that's the case, what are you circumventing if the antibody reacts at 37 and you are transfusing at 37? Nothing. The idea of using a blood warmer is to keep the temperature of the transfusion ABOVE reaction temperature. If you have a cold agglutinin with a thermal amplitude above 30C, a blood warmer is not going to change the reactivity and the MD needs to start thinking about reducing the antibody concentration and/or production (pheresis, medication) rather than a risky transfusion ... the patient will destroy the donor RBCs just as quickly as the auto RBCs and may even exacerbate the problem (introducing new antigens, stimulate the immune system).
I agree with your 'caution, best to use a blood warmer': To assure we are all applying the same rules for every patient, I have instructed my staff to issue RBCs with a blood warmer if they see a demonstrable cold agglutinin at the Immediate Spin/Room Temperature phase (we routinely perform this phase with pooled O cells during initial pretransfusion testing to look for 'room temperature/close to infusion temperature' cold agglutinins and rouleux so we have no such surprises later during crossmatching). Is a blood warmer always needed for these cases? Probably not ... but it is the safer side of caution and provides for continuity of a policy. We can do this automatically because it is written into our procedure which is in reality our Medical Director's instructions to us ... yes, she signs all our procedures ... hence, it is a physician's order.
Maybe your supervisor will consider putting such a policy/procedure in place for everyone to follow ... rather than you acting on your own.

I wouldn't think you need to create a new policy, you should already have a policy regarding situations requiring path approval or regarding a deviation from your SOP. Agree with what was mentioned previously in that a conversation must happen with your medical director and ordering MD. The blood shortage is worldwide with the donor pool going up and down so this shouldn't come as a surprise to the MD.  We also switch male patients (not that often) but the MD's understand the situation. We note it in the patient files the date and how many Rh pos units were transfused just for tracking and in case an anti-D is made. 

I'm going to be blunt.  This is ridiculous!!  You have the potential of causing far more problems by removing the cubes from their protective container.  

Does your Pathologist not understand that Lewis antigens are not intrinsic to the red cell membrane (in fact, in all probability, if they were discovered now, they would almost certainly NOT be recognised as red cell antigens by the ISBT).  As such, even the small amount of plasma contained in packed red cell units is sufficient to adsorb out most of the patient's Lewis antibodies in vivo, during the actual transfusion.  Those transfused red cells that survive in the circulation (i.e. about 100%) will very quickly assume the Lewis type of the recipient.  He or she might like to read Sneath JS, Sneath PHA.  Transformation of the Lewis groups of human red cells.  Nature 1955; 176: 172, as this may serve to stop the worrying.

Mine states the units are incompatible and gives the reason for the incompatibility.  

We issue units for warm auto cases as 'incompatible, approved by pathologist'. We enter a comment in the patient Blood Bank record with the date/time we got the approval, from whom, and documentation of any instructions they give and any instructions we are asked to pass on to nursing. In some cases, the pathologist may consult with the ordering provider and request that he/she sign a 'Request for Release' form with one of two options selected:
- incompatible units due to clinically insignificant interference (cold agglutinin, rouleaux, etc.) OR
- incompatible units due to interference from a clinically significant warm reacting autoantibody. Although some units may appear compatible in vivo, it is impossible to rule out any underlying clinically significant alloantibodies that may cause a hemolytic transfusion reaction.
The pathologist may also sign the release form in some cases, if requested by the provider.
 

Does the patient have ITP? Is it possible that she is receiving WinRHO (same as RHIG) for ITP? Does she have a low platelet count. I haven't seen this situation in several years but there was a time when patients with ITP who were rh pos would be treated with WinRHO (as long as they had their spleen). It would present as this very scenario you are describing.
Another possibility is anti-Lw?

Re:  We still have concerns about pre-op patients who aren't wearing any Epic band to scan when their pre-admit specimen is drawn. (I'm taking advice on how others manage these.)  Likewise for outpatient transfusions. 
Epic told us that their system is not designed to use the process of banding outpatients and pre-op patients.  WE INSISTED since 1) we've always banded any patient getting their blood drawn... especially for blood bank testing, 2) we were determined to meet AABB Std. 5.14.5.3) requiring an electronic (scanned) identification system, and 3) we decided that we were NOT going to go backwards after all these years and create a new system in Epic that was less safe just because they said that's their design.  I insisted that PPID scanning be used for the specimen collection/labeling and that the same armband be presented on the day of their admission or outpatient transfusion. The patient is given strict instructions (an instruction sheet that they must sign and is scanned into the EMR) that they are to keep the band on or at least have it in their possession on the day of admission/transfusion. The original band used for specimen collection is replaced with their new encounter band only after the 2 bands are compared side-by-side and match exactly for Name, MRN, DOB.  It was a bit of a struggle to get everyone on board to veer from the Epic "Foundation" methods, but we were finally able to convince people that this was a significant patient safety issue and was necessary.

I don't think that is correct about dumbing down to manufacturer's recommendations.  I believe the regs read that at a minimum, manufacturer's requirements for things like QC be followed.  CLIA/JCAHO/CAP regulations are often much more strict than what a particular manufacturer may suggest for their product. 
If you choose to not run a pos and neg control, you better have a better reason than, "the manufacturer said it was OK."
Scott

I like “Reactive”, though we use “least incompatible”. I think change is the issue as the the questions about meaning would last years!! 

Hi Malcolm,
What terminology is recommended in these situations? We have always used "least incompatible" in the states. I think, probably, the majority of our databases have that option listed besides "compatible" and "incompatible." What terminology should replace "least incompatible?"

To emphasize Exlimey's point: 
"One event does not indicate a trend - changing the whole system to address a single cut-finger incident is unreasonable". Also of concern is the use of plastic, who knows in the near future if this will be available in test tube form in abundance? We need to look at how and why this accident occurred? Everything in our lives cannot be padded so we don't fall, trip, get our feelings hurt (sorry had to add that), or get a cut. I know it's very serious to get a cut from a blood-contaminated item but I personally would look at what is reasonable and prudent. I know we have 'seasoned' techs on this site, probably 20-30 years in the field that would think it strange for that incident to happen, I would think getting a cut from grabbing "clean" tubes from the dispensary would be more likely because you are grabbing a bunch of tubes but normally you grab tubes with samples in them (contaminated tubes)  from either the centrifuge or tube rack and can clearly see what you are grabbing. 

To emphasize Exlimey's point: 
"One event does not indicate a trend - changing the whole system to address a single cut-finger incident is unreasonable". Also of concern is the use of plastic, who knows in the near future if this will be available in test tube form in abundance? We need to look at how and why this accident occurred? Everything in our lives cannot be padded so we don't fall, trip, get our feelings hurt (sorry had to add that), or get a cut. I know it's very serious to get a cut from a blood-contaminated item but I personally would look at what is reasonable and prudent. I know we have 'seasoned' techs on this site, probably 20-30 years in the field that would think it strange for that incident to happen, I would think getting a cut from grabbing "clean" tubes from the dispensary would be more likely because you are grabbing a bunch of tubes but normally you grab tubes with samples in them (contaminated tubes)  from either the centrifuge or tube rack and can clearly see what you are grabbing. 

To emphasize Exlimey's point: 
"One event does not indicate a trend - changing the whole system to address a single cut-finger incident is unreasonable". Also of concern is the use of plastic, who knows in the near future if this will be available in test tube form in abundance? We need to look at how and why this accident occurred? Everything in our lives cannot be padded so we don't fall, trip, get our feelings hurt (sorry had to add that), or get a cut. I know it's very serious to get a cut from a blood-contaminated item but I personally would look at what is reasonable and prudent. I know we have 'seasoned' techs on this site, probably 20-30 years in the field that would think it strange for that incident to happen, I would think getting a cut from grabbing "clean" tubes from the dispensary would be more likely because you are grabbing a bunch of tubes but normally you grab tubes with samples in them (contaminated tubes)  from either the centrifuge or tube rack and can clearly see what you are grabbing. 

To emphasize Exlimey's point: 
"One event does not indicate a trend - changing the whole system to address a single cut-finger incident is unreasonable". Also of concern is the use of plastic, who knows in the near future if this will be available in test tube form in abundance? We need to look at how and why this accident occurred? Everything in our lives cannot be padded so we don't fall, trip, get our feelings hurt (sorry had to add that), or get a cut. I know it's very serious to get a cut from a blood-contaminated item but I personally would look at what is reasonable and prudent. I know we have 'seasoned' techs on this site, probably 20-30 years in the field that would think it strange for that incident to happen, I would think getting a cut from grabbing "clean" tubes from the dispensary would be more likely because you are grabbing a bunch of tubes but normally you grab tubes with samples in them (contaminated tubes)  from either the centrifuge or tube rack and can clearly see what you are grabbing. 

To emphasize Exlimey's point: 
"One event does not indicate a trend - changing the whole system to address a single cut-finger incident is unreasonable". Also of concern is the use of plastic, who knows in the near future if this will be available in test tube form in abundance? We need to look at how and why this accident occurred? Everything in our lives cannot be padded so we don't fall, trip, get our feelings hurt (sorry had to add that), or get a cut. I know it's very serious to get a cut from a blood-contaminated item but I personally would look at what is reasonable and prudent. I know we have 'seasoned' techs on this site, probably 20-30 years in the field that would think it strange for that incident to happen, I would think getting a cut from grabbing "clean" tubes from the dispensary would be more likely because you are grabbing a bunch of tubes but normally you grab tubes with samples in them (contaminated tubes)  from either the centrifuge or tube rack and can clearly see what you are grabbing.