seraph44

Hi Scott, This is what they are stating here. Which tells me that they are not checking the blood before it gets hung. They say they use a white board but I'm almost certain they are not checking the blood with the white board and I don't think that's acceptable (I can't find literature on this at least). I'm concerned because several times they send a courier that is not involved with the case to pickup blood and if there are two patients receiving blood and the courier takes it to the wrong room, this can lead to some serious issues if they don't properly check the patients and the blood.

Hello Blood Bankers, Have any of you encountered issues with PPID of patients in the OR in a sterile field? Some colleagues and I are trying to see if there is a way to properly verify the patient in during a surgical procedure when their armband is hidden due to a sterile field. Since a whiteboard, or room number is not an acceptable form of identification, what are other facilities doing in this case? Is there any literature with guidelines regarding this? Thanks,

We used to have Typenex but we removed them since they were causing more problems than anything. We collect two specimens to verify we have the correct patient, if only one sample is drawn, we give group O until we have a second sample collection. We also allow for the use of a hematology specimen to verify our blood type.

The forward type is an AB patient, your reverse type looks like you have multiple things going on. Because of the negative xm with group O donor red cells and the 1+ reactions with your group A donor red cells, I suspect an anti-A1. However, that 4+ reaction on the B cells cannot be due to the anti-A1 and I highly doubt that it is due to rouleaux; At least from my experience I don't typically see rouleaux this strong and we should have seen it with similar strength against the A1 cells. I agree that you probably have a cold reactive allo antibody going on with the B cells. In order for you to clear the ABO discrepancy I would do an IS antibody screen and see if you find a patter for a common cold antibody. Hopefully your find something; if you find a Lewis antibody I would find some random group B units and you should statistically land on one that can give you a negative result against your patient plasma to confirm it is not an ABO incompatibility issue. If you find something like an M, you could antigen type a group B unit but that will take 5-6 units before you find one, and then test it again your patient plasma to confirm negative results. The easier way out is to prove your anti-A1 and then take your reverse cell testing to the AHG phase to rule out ABO incompatibility. Consult with your pathologist of course, since this might be out of your standard operating procedure.

Hi everyone, I'm trying to get some feedback on transfusion reactions. If you have a dialysis patient with a base line BP of 130/54 and they're trying to get in a unit during the dialysis treatment in 40 minutes. This causes the BP to clime up to 170/75; most likely due to the rapid transfusion right? Would this be considered TACO if the patient doesn't present any symptoms of decreased pulse ox or dyspnea, etc...? Another question is, if the base line BP of a patient is progressively rising during a 2 hour transfusion to the point that the final BP is significantly elevated when compared to the baseline but not when compared to the others, would this be indicative of TACO? Does your facility count it suspicious if there is significant difference from the baseline or significant difference from the previous vitals. I would add that in my personal opinion I do not consider the increase in BP alone to indicate TACO, but if you have no other documentation in the patient chart or transfusion record, you assume the nurse did not assess the patient right? How does your facility handle these situations currently? Thanks, Serafin

Yes, re-portable. It the only exception is during an emergency release. Since it most like is not part of your SOP to overlook the positive AB screen, it is re-portable. contact them and they are very helpful about providing you with the correct info.

We will be moving our RhIG to the pharmacy within six months. I find a bit confusing because of how I've handled RhIG in the past. This is what JC currently says: QSA.05.13.01 1 The laboratory’s written policies and procedures for the administration of Rh immune globulin address: - Criteria to identify patients eligible for prophylaxis - Procedure to determine dose of RhIG required - Optimal timing of administration following exposure QSA.05.13.01 2 The laboratory follows its policies and procedures for RhIG administration. Once RhIG is moved out of the Laboratory, do we still monitor if the patients received RhIG appropriately? The part of "Criteria to identify patients eligible for prophylaxis" has me wondering. We will have doctors order a "Trauma KB" and a "Post Partum KB". This is easy to keep track off, but how do you keep track of a typical pregnant female with vaginal bleed and they order and an order for an ABO/Rh through the E.D.? Do the folks who no longer dispense RhIG have to pull any reports to and go through the trouble of making sure that all eligible patients received their RhIG? or is this something that pharmacy has to do? Would you all agree that the criteria to identify patients for prophylaxis should not be applicable to the blood bank since we no longer dispense? I would assume our only responsibility should be to perform the testing and for the pharmacy to now have a checklist to determine eligibility. Thanks,

Thanks everyone, this is great info...

I have an interesting case where the E.R. physician ordered 2 units of Emergency Release red cells. They got them and transfused one. The patient was transferred to the O.R. for an emergent procedure and received the second unit there. Does the physician requesting the emergency blood sign it? or does the physician responsible for the patient during the transfusion sign in (in this case the O.R. doc)? Thanks,

If you have Cerner you could probably have an option to report as "see comment". Then put the results as "result comments". To protect the baby from getting antigen positive blood, you might have the feature to add transfusion requirements (these can be added and removed as needed). In this transfusion requirement option you can select something like "Give O neg blood" and "little-c negative RBC). The logic in the system will warn you if you try to give anything that does not meet that requirement. After the neonatal protocol period, you can remove these requirements.

We do as your new supervisor states but without the DAT (unless the autocontrol is positive). An even when a patient has a history of let us say, little-c, we only run the cells that are little-c negative. By this time you should have done a screen and determined that little-c was still present. Anyway, this will allow you to waste time on cells that will ultimately be positive and not useful to rule out the other clinically significant antibodies. There is no need to re-identify little-c again anyway, since you have a history and are required to give little-c negative red cells.

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. The Case Definition gives physicians and pathologists a criteria they can use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive: New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:  Acute respiratory distress (dyspnea, orthopnea, cough)  Elevated brain natriuretic peptide (BNP)  Elevated central venous pressure (CVP)  Evidence of left heart failure  Evidence of positive fluid balance  Radiographic evidence of pulmonary edema It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined.

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. The Case Definition gives physicians and pathologists a criteria they can use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive: New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:  Acute respiratory distress (dyspnea, orthopnea, cough)  Elevated brain natriuretic peptide (BNP)  Elevated central venous pressure (CVP)  Evidence of left heart failure  Evidence of positive fluid balance  Radiographic evidence of pulmonary edema It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined.

At a previous facility we required only one specimen with two signatures, we would give ABO/Rh specific, we used pink top tubes, and we extended to 14 days for those who met the criteria you mentioned. This was 4 years ago by the way. We used to have a file specific for 14 day hold patients and XM them the day prior to surgery. Currently we don't have patients who required extended XM but do have outpatients who return a day or two later. We do require a separate collection before giving ABO/Rh specific. We leave the "crossmatch/product request" open and request an "ABO/Rh recheck" upon their return for surgery if the patient is anything other than group O. If the patient is O we setup the product without a second sample. Upon return for surgery, the ABO/Rh recheck is drawn by the nurse upon starting the IV and sent to the blood bank. At this time, we perform the recheck and complete the crossmatch.

At my prior facility we used to constantly get patients with positive antibody screens due to antepartum RhIG. In order to help differentiate between passive and active immunization, we performed a 1:4 titer on the patient's plasma. If the titer was greater than 4, we would suspect active vs passive. We never had one over 4 as far as I can remember. I don't recall were they obtained the reference material, but they are AABB, FDA, CAP, and JC accredited. Hope this helps.

They need a minimum of two identifiers. There are cases when there is a newborn or unidentified person requiring blood. It is NOT the Blood Banks responsibility to identify the patient, but we are required to have two identifiers. Nursing should have a process to apply aliases to those patients that are not registered or have not had their identities verified. Imagine a motor vehicle accident with 4 or more people needing blood at the same time. We need to have 100% traceability of those units. A lookback is an important reason as to why we need to have 100% traceability. We've had a similar problem and it is a difficult task to get nursing educated on their requirement to identify patients with an alias and another identifier or whatever system they deem appropriate.

If you receive a new pipette with a certificate of calibration, do you still perform in-house calibration, or do you do it once the certificate expires?

I just got inspected by JC and got hit on my Ortho panels. They recommended I do QC with a diluted anti-D on each panel to ensure the panel is working according to manufacturer recommendations. I've been looking into this for a bit now and I plan on making the the following change to my process. This process is the same for both my in date panel cells and expired cells. Ultimately, the reason for all of this is to prove red cell viability. We all perform quality control on our screen cells; I use a QC kit. We then test a patient that happens to demonstrate one or multiple reactions on the detection phase. This patient sample is now used to QC our panel cells. We basically validated our patient with cells that were QC'd. When running the patient (QC sample) against the panel cells, we will detect positive reactions, proving the viability of the cells. When doing additional rule outs, I will also select a cell that is positive for the suspected antibody, to ensure I also get a positive reaction there. Basically, every panel I use will have at least one positive reaction to prove red cell viability. If no reactions are noted, I will have a troubleshoot guide (repeat testing, try a different panel, repeat AB screen, antigen type panel, etc...). I plan on using this same process to prove red cell viability in expired red cells. I think this is safer than doing random QC for a limited number of antibodies, you are ensuring the reactions on the QC'd screen cells are reacting on the panel each time you have a positive antibodies vs. "Should periodically perform quality control on panel cells" as stated by the manufacturer. As far as the disclaimer goes, I think I will wait for something more concrete for these inspectors. I am currently working on responding to JC with this process and see if they are in agreement.

Currently at a small community hospital; about 130 beds. We have a Pathologist that oversees the whole lab, but Transfusion Medicine is not his strength. He is part of a group, which he can reach out to in a given case. I typically take most calls, because they are mainly technical questions. We have all generalist that are trained in Blood Banking and always have questions. I previously worked at a level 1 trauma hospital and we had 1 Pathologist and 1 Transfusion Medicine Director. We had guidelines as to when to call either of them or both of them. Guidelines to call the Director were mainly technical or equipment issues. Guidelines for the Pathologist were for suspected transfusion reactions, attending inquiry, etc...

I currently use a Rhig panel/D panel when I have reason to suspect a passive or allo anti-D. We currently use selected cells to r/o all common clinically significant antibodies with 1 homo cell. The exception is the C,E, and K antigens, for which we use 2 hetero. I've heard arguments about getting the same reactivity whether you use 1 or 5 hetero and that it technically doesn't matter. Does anyone here also have a D panel? and does it rule out the antigens mentioned above with 1 hetero or 2 hetero? Thank you

Was the patient septic prior to transfusion? Any pre blood cultures done? What about WBC prior to transfusion? We had a similar case not to long ago, two units were the temp spiked on the patient 2 degrees and both workups were negative. Unlike yours, we had no blood in urine or other abnormal labs other than elevated WBC count. We did culture the units for 5 days with no growth as final.

I reported the issue to Ortho and they wanted to point the finger at us vs. the reagent. I concluded it was a combination of both the antisera and the panel cell being near expiration. Even though I used another panel cell that did react at 5 min, it is my secondary panel which is better preserved. My corrective action will be to recommend a RT incubation of 10 minutes. This is because I had 2 different hetero cells, which should have reacted at 5 min RT incubation, but only 1 did. What can prove the same thing cannot happen to a short dated unit of blood? I would hate to call it negative after 5 minutes when it really is positive. Thank you all for your feedback.

I am using ortho for my antisera and ortho for my panel cells. I will be testing the cells with a 10 min RT incubation. If that detects it, i'll revise my SOP to 10 minutes like Anorris mentioned. I guess I can notify the ortho about it as well. Thank you,

Hello Blood Bankers, I recently ran into my first unsatisfactory Antigen typing QC. A tech performed QC for an "e" antisera using a heterozygous cell. Results were negative at IS and negative after 5 min incubation. This was repeated by the same tech and later repeated by myself:Results did not change. The "e" antisera was ran with a different heterozygous cell and results were negative at IS and 2+ after 5 min incubation. Both the cells and the antisera were near expiration date. However, I'm a bit confused as to what corrective action is needed. How do I prove my panel cells are working correctly and how do I prove my antisera is working correctly? I think I proved my antisera is working correctly by running it with another Hetero cell. Should I run my panel cell with a new antisera to prove the panel is "e" positive? Thank you, Serafin

We practice the 4 hour rule from the time of issue, but my previous experience and the circular of information state it should be 4 hours from the time the unit is spiked.