MERRYPATH

We go by 100 days post last transfusion...alert...they may be transfused elsewhere, take the back type to AHG, the case is sent to the BBDoc for evaluation and they will also check % engraftment. PatO at 60!!!

I am guessing that the rate mom was producing an early anti c, in respose to a c pos stimulation from baby, was slow enough that it was hemolyzed before it was detectable. When the baby was out of the loop the Anti c was no longer taken up by the baby cells and the mom was increasing the speed of production. I would guess that the anti c that reached the baby was all hemolyzed and that is why the DAT was neg. Maybe the question would be, is the baby nursing, how long does the mom produce colostrum that might contain anti c. Is it hours or days etc. if this is not an issue the baby can no longer get anti c passively so it should be fine with c untested. Our protocol is to do a BTYSC (baby type and screen that includes baby screen, baby front type, baby DAT) the only way I can see needing to give c neg is if the crossmatching is done with mothers blood to avoid unnecessary draws on baby, we would do this if we have an unident aby on mom. Now I am confusing myself. PatO at 60!!!

Anyone else encountering Blood Bank problems with the drug Daratumumab? We get positive screens in gel, auto is negative, we repeat the screen in saline. if it is negative we proceed and work in parallel with gel and saline. If the saline screen is positive we send to ARC and they do DTT treatment to get negatives...as soon as we develop a procedure we will do our own DTT treatment. I am guessing 1/3 go to ARC. Our BB Docs are letting us know when they come in system...we do Kell typings before they go to ARC if they have no transfusion history, otherwise we give Kell neg. Big headache, hard to explain, causing delays in people who are used to no problems getting transfusions. So just letting people know that when you start seeing this drug causing problems get you docs to look into it. PatO Now 60!!!

In the last 15 years we have had several people retire from our BB and go to work at the ARC reference lab part time. We are our own hospital systems reference lab so we are accustomed to very complicated aby pictures WITH the added pressure of completing our reference work while operating the usual BB duties. I think also that the older techs have a greater tolerance for misery and don't tend to quit if the pressure is to high. Our local ARC reference lab seems happy to get us even if part time. Many of us tend to stay on in the lab as well...I am soon to turn 60 and have no plans to stop, I like blood banking. The usual reason people have retired is the pressure to do venipuncture and cross-train(or rather to work other areas with insufficient training). As challenging as our Blood Bank and reference work is the venipucture here is also only for those with the "right stuff'. It is just not fun to have to do several hours of venipucture on very difficult sticks after 30 years of not having that as part of your duties. I would bet reference jobs in blood banking would welcome your experience and discipline...blood bankers show up.

I was thinking more about the need for modern RBCs to be at risk if only out 30 minutes...or less. I wonder if the risk is so much less today that the 30 minute rule is only serving to waste a precious commodity. I agree that if the requirement is to keep the units under 10 degrees 30 minutes is the limit but if the actual danger zone is an entirely different temp range then the practice of the 30 minute rule is as obsolete as other practices we squirmed when we gave up...not looking micro is still hard for me. I think the 30 minute rule at least needs to be proven as necessary considering todays cleaner units. I think that using old practices as iron clad leads to stinkin' thinkin' as we know that there are contaminants that thrive at refrigerator temps as well as tropical temps.

I think that the 30 minute rule may be out of date for 2015...at least it seems to have been in 2013. I want to not toss units based on old practices. http://www.ncbi.nlm.nih.gov/pubmed/22845177

Isn't the very act of doing a panel also doing a kind of QC of the panel? Cells being positive or negative in a predictable pattern. When we get no reactivity or unknown reactivity on a panel we run a second panel to confirm the lack of a pattern or to find a pattern. With an allo we may confirm with an antigen typing. We are also confirming with xm of antigen negative units. The whole process of an antibody work up is check and double check.

First we do still use a microscope though now mostly for DATs which we still do in tubes and read micro. We are looking at changing to Poly gel card but I think our first handful of samples done both ways are an interesting mish mash of results. While we are a hospital Blood Bank we also function as the primary reference Blood Bank for the system so I would be squeemish about not having a microscope. We see lots of cold antibodies at times and lots of rouleaux...I just want to SEE sometimes what I am dealing with. As we are now not reading antibody reactions micro I am pretty sure that a 1+ gel is more comparable to a micro reaction than a macro tube reaction. Another issue I have come to find in our dalliance with a few years of Capture testing is that we lost a lot of skill at recognizing the affects of cold aby and rouleaux as they affected Capture testing. When you have SEEN a lot of colds and rouleaux you can SEE how they affect Capture and gels and tube testing. People with only Capture experience came to have unrealistic expectation of what you could expect from Capture testing...to me it was just another method at MY service...just a PART of the whole picture. I think the difference was having known blood banking through many years macro and micro is very helpful to me when resolving problems. IS micro a pain sometimes...TMI...yup but sometimes it gives me the knowledge I need to come to a conclusion.

We have dropped the sex and use Baby1 and Baby2. Our protocol does keep the last name of the mother and the first name as you suggest for babies born in system...we have had a problem (or two) with different named babies and mothers matching antibody histories to what we find in a baby. We have our own NICU for our state wide system as well as receiving babies from outside our system so we are not just dealing with our in house naming protocol and it DOES matter when resolving antibody situations, if they give the baby a name before it comes to us...hate it when that happens as I am the oldie but goodie and I am supposed to pull this information from deep memory like my idol Jane Swanson can do...remember the mothers name by her antibody list...Jane is close if not 90 and she could still today pull those out of where she hides them. We have stopped sex assigning the babies as there is a lot more known about what affect this can have and more information is needed before some babies sex can be clearly understood.

I am getting confused in my D antigen thinking. I work at a BB that is fully capable of using a regions whole supply of RH negative RBCs. When we get into a shortage it is easy to look back and say this should never have happened and that should never have happened. While in the situation I think I need to push harder and stomp my foot more to switch to RH pos RBCs. On the other hand I am not the physician and I am concerned that my years of experience be used as a force for good and not evil. I am always thinking of changing to RH pos when we are getting to 8 units or more of RH negative RBCs...I am guessing most of you are thinking why so late...we have a good supply of all types generally. We are also seeing surgeries where they are 2 and 3 times or more into many patients, it can be a population of people who have multiple transfusions in their past...sometimes even RH neg patients who recd RH pos units their last OR. We actually see very little of the emergency uncrossmatched patient, but we see a lot of the issues of chronic transfusion, so I am wondering if switching RH neg patients to RH pos will be more problematic in our patient population. In the usual hospital situation a need for transfusion is transitory and those patiens my never be transfused again, in our situation they are likely to need to be transfused and soon. So we give RH pos to an RH neg person in a bad CABG, their 2nd or 3rd, or maybe an LVAD...the patient ends up on ECMO for weeks to a month and many more transfusions to come and then pehaps their heart transplant. If they DID make anti D it would finish them...right? I know that is the fear of the docs we go to for approval. How do you all look at this issue? Thanks

Infection Control is where the information is directed. Blood Bankers makes a smear and culture bottles (aerobic and anaerobic-which are sent to micro) from the remains of the unit and from a tube drawn post-reaction, retypes the patient and does the DAT...what happens from that point varies with results.

We do 1 to 30 days prior to surgery. We have the 3 questions whose answer must be no...has the patient been transfused? Has the patient been pregnant within the last 3 months? does the patient have a history of an antibody or transfusion related complications? Then the 2 questions...Has the patient been transfused withing the last month? Has the pastient been pregnant withing the last month? also must be asked withing 3 days of surgery and answered no. So the questioner signs the first past and the new questioner signs the recheck part which is returned to the blood bank. When I recieve the first part I put a comment in BAD...preadmit order recd (date) for procedure scheduled on (date) or perhaps with an unknown date. Tubes are saved in their racks for 37 days. If they have not answered a question correctly we respond saying they are not eligible for extended xm and must be redrawn withing 3 days of procedure and post it to chart.

I am confused...as per usual I will soldier on and say what we do. I am not sure how you detected the anti M(just saw the title...on TANGO)...if that was part of the history from another institution. We honor any information we can get our hands on. If we discovered a history elsewhere, in EPIC it is listed as CARE EVERWHERE, we honor it. We run our own workup if our Screen is positive. We don't depend on CARE EVERYWHERE...we still call and ask for additional transfusion history. So we would honor the Anti S...if the Anti M is not reacting we would not be typing for M. If you do your crossmatches on Tango then units would be S neg and crossmatched. If the M was reacting in the crossmatching method we would decide where the most annoyance would be...crossmatching for compatible or typing for M. Often if the patient is reacting with Heterozygous M cells I would type for M. If she is not reacting in my crossmatching method I would not type for M. Is it significant...the OB doctors like to make us titer Anti M...I am sure somewhere at some time there is a paper with such advice...and we have been titering Ms ever since.

AFP=APHERESIS FROZEN PLASMA

We scratch out the US license number when we attach a new label...our component label is a computer generated half label applied over the bottom half of the original product label. That half label has our Processed By: information with our FDA regustration number. We do not scratch out the original FDA Registration Number for the original supplier just the License number. In days gone by we had a separate sticket for each part as we relabelled components.

We receive FP, FFP and AFP from our supplier. Mostly FP and AFP. Once thawed it is relabelled as Thawed Plasma with a 5 day outdate.

We run a BTYSC...a baby type and screen. It includes a type, and we do not do the backtype for babies, a screen, and a tube DAT. If we get a pos DAT we look at the mothers TYSC. If the pos aby screen or DAT can be justified logically by the mothers results we do not continue. If we do not have a TYSC for the mother we request a draw or research her results at another instutution. We will do the ABID on the mother if at all possible to save the baby any draws. In the rare occasion there is no way to compare the mothers type and current screen then we might request another draw of the baby and or pursue the baby workup. The most complicated workup I remember was a baby with multiple antibodies and a positive DAT. One of the legends of Blood Banking, Jane Swanson, happened to be visiting and I listed off the antibodies found and she immediately rattled off the name of the mother...whose name was not the same last name as the baby...it had been over 10 years of retirement and her mental index and boundless knowledge is sharp as the day she left. So even in her 80s she can still problem solve for Blood Bank. So ultimately if we can solve the problem we do not continue with the workup. I forgot to mention that most BTYSC are done for the babies in the NICU or for babies with moms who are RH neg. Otherwise we may have the cord blood sent to the BB with no tests ordered...just in case. We are also giving all babies type O or O neg fresh(less than 7 days) Irradiated and, if there is/or mom has an allo antibody, antigen neg. We try to keep babies on the same RBC unit, so to reduce exposure to multiple donors that might go over 7 days, as long as they are not using over 30 mls per transfusion, if they are transfusing over 30 mls we use fresh RBCs(<7days). The BTYSC is good til they are >4 months. Also we continue Irradiated RBCs until 6 months. In the rare instance there is a non allo antibody that requires xm we can xm with the mothers plasma on a current xm and we continue as long as the DAT is pos. Our NICU has a fulltime lab staffed with a BB trained CLS.

Again I work evening shift...my viewpoint is that most units are returned unused from ORs so I generally release the majority of returned units. If they are antibody units we have a shelf where we keep antigen typed units so unless the patients go to a critical care unit I will release the units. In our system they can quickly be reset up and re tagged based on the current xm if needed. On the days prior to ORs the day staff searches the list of pending OR for people with antibody histories coming for the next day ORs and we give the list to the attending who will let us know if any units should be available...just in case. We used to automatically do 2 units ahead on all antibody patients in OR...actually at one point in my career even if they were IN house. But that went the way of Irradiating all of a few stations RBCs just in case they made a mistake requesting Irradiated units...we don't do that any more either. Someone checks the antigen typed unit shelf to monitor outdates for those units and they go to general inventory at some point. I am personally reluctant to use any outdating antigen typed RBC on the suspicion that as soon as I use the unit I will need the unit...kind of a superstition. If they are outdating imminently I will use them and knock wood. PatO

We are doing an anti M right now. It was pos on a specimen from the 1st...M homozygous reactivity...they shipped the patient to us with one emergency unit transfused(M pos of course) The tysc drawn today (on the 3rd) is negative. As a curiosity we were hunting for SOME reactivity in our specimen and did find a pos DAT. Our protocol for anti M is to either xm for comp or give M neg computer xm IF the anti M is reacting. Once the anti M is not reacting we go back to computer xm and M neg is no longer required. We decided to honor the pos from the 1st and continue long xm, though if they are a big user we will order or type for M antigen as it saves time especially on the short shifts.

I speak as a Blood Banker on evening shift. When we have a STAT type and screen and we have a positive screen, either previously pos or a new pos, we have a worksheet Antibody Screen Positive-Evaluation Form. The form asks a number of questions to determine if a new workup is required. We notify the nurse of the Critical Result and document. We also answer if there is a STAT RBC order present...Were emergency units offered to the PCU...Was the Blood Bank Physician notified...These questions are intended to involve the BB Doc at the time the patients team is deciding if they need to transfuse in an emergency. As often as they are afraid to transfuse with the presence of an antibody they are also without fear to transfuse if the are thinking emergency in their minds. It can be foolish either way. We get the BB physician involved to be the go between...with two blood bankers on evening shift we have to stay on task and get as much information as possible advanced as quickly as possible in the work up so the BB Doc needs to step in to evaluate what is happening. In the past we did not necessarily involve the BB Doc and our bigger problem was that the patients team would not communicate an emergency need once we said "antibody" They might wait when they needed to transfuse. We don't often have a true exsanguinating emergency with no prior history. Our emergencies will happen more commonly with ORs gone bad or sudden changes of status on the floors or a patient coming back in via the ER. When we do have a Code Red called in ER we send 2 O negs with our Emergency Release. The beginning of a Massive Transfusion Protocol with an antibody patient may begin with 2 uncrossmatched units if we do not know the name of the patient. Once we know the name we we can alert the team to an antibody history. Alert the BB Doc. Start looking for a tube to begin a workup with. I have gathered antigen negative units...we often have a variety of antigen negative units in inventory..to meet the emergency needs of a previous anti E with an Anti Jka for example. I can pull units that are set up on other patients as well. Then I have the option of untested RH negative units to make a best chance at E negative. We copy the faces of the units and pull a couple segments for later typing and crossmatching. I have had the local ARC and our own Blood Bank inventory entirely typed over a long night. You do the best with what we have both in personnel and blood supply. One night a man with 5 antibodys and compatible with less than 1% of the populations got close, closer, closest units available with the thought of saving the 7 units negative for his antibodies til the end of the procedure...when they were least likely to be bled out. He survived and made 2 more antibodies.