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Posts posted by exlimey
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8 hours ago, Neil Blumberg said:
Just the person you want operating on your brain or reading your prostate biopsy, no doubt. Makes one proud to be a part of the same profession. Not. Pettifogging fool. Perhaps he is nice to his dog and children.
"Pettifogging".....an 'olde worde" that is so relevant today. Thank you for reminding me. I shall try to work it into as many conversations as possible.
- Ensis01, John C. Staley, Malcolm Needs and 2 others
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16 hours ago, RRay said:
I've had this come up before with incomplete transfusion history (transfusions at another facility) and with IV drug use / sharing needles. Occam's razor?
Agreed....history is always a wildcard.
I had a case once where there a teenaged male individual had antibodies to red cells (I can't remember the specificity) with no apparent transfusion history. Later questioning revealed that the person was part of a "Blood Brothers" group who routinely and ritually exchanged blood through self-inflicted cuts. Each to their own.
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I was also thinking of a prior sensitization. A weird, barely detectable D+ phenotype may not generate a new immune response, but may be enough to reactivate the primed lymphocytes in an individual who's anti-D has faded into non-detectability. Tiny re-exposure and wham ! Nice, strong, clear-cut anti-D, apparently out of nowhere.
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1 hour ago, Bet'naSBB said:
We "want" to say this is an anti-G - but, there's absolutely NO anti-C reactivity.
Reading between the lines, I believe you're saying that C+D- (r'r) panel cells are nonreactive, thereby excluding the presence of anti-C, If that's the case, and since said cells should carry the G antigen, it is very unlikely you're dealing with anti-G. Anti-LW may mimic an anti-D pattern by demonstrating reactivity only with D+ cells.
It's also very remotely possible that one of the donors carries a rare form of D-antigen that is not readily detected by typical commercial reagents. However, those are very rare and their ability to stimulate an immune response is not well understood.
- jshepherd, Ensis01, Malcolm Needs and 2 others
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In this case, the Safety goons may be your very best friends. If the space you describe is really that bad, you could use the safety angle as leverage. Alternatively, modern instrumentation (including the Ortho Vision) often has very specific installation requirements (space/clearance/ventilation, etc)....that may ammunition, too.
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On 9/23/2022 at 3:40 PM, RRay said:
Thank you! Got some great lay out ideas! much better than what I currently have. Seems like the last person in my position had a very "horizontal" brain where I am a "vertical" kind of person. Haha!
Careful, now. You're bordering on "spatial discrimination".
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On 9/23/2022 at 3:42 PM, Malcolm Needs said:
How about a "Del" ? Fits the description perfectly.
One the other hand, "twice in the last few days" is worrying. While not impossible, it's highly unlikely that a facility would encounter more than one of these anomalies (zebras) in such a short period. I assume Malcolm's question regarding the Last Wash is an allusion to some laboratory artifact - bad technique, bad reagents, etc.
- Malcolm Needs and SbbPerson
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50 minutes ago, Bet'naSBB said:
@exlimey if a Lewis antibody is identified - we type the patient...... it's just how our protocols are written. The only time we would be required to provide Lewis antigen matched units would be if the antibody demonstrates hemolysis at AHG otherwise just XM compatible. Do I know why? not really - I've just been doing what I was told......for almost 35 years.
Understood. There are many things laboratories do because they've "always done it". Those in the decision-making roles probably saw a "bad case" somewhere along the way and it stuck in their brains. I will concede that there are a smattering of cases of Lewis antibody-mediated transfusion issues to reference, but most workers consider them an insignificant nuisance.
- Yanxia and Malcolm Needs
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50 minutes ago, Ensis01 said:
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Excellent point, Ensis01.
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An interesting case/issue. I agree with your premise: doing anything to make the saline control nonreactive (warm-washing, CDP, acid-elution) will probably make the test with anti-IgG negative, too (assuming the positive saline control is due to IgM-coating of the patient cells, causing direct agglutination).
Perhaps a DAT with an anti-IgM reagent could be arranged ? Did you try a DAT with polyspecific antiglobulin reagent or a monospecific anti-Complement reagent ? But even results from these could be "invalidated" by reactions in the so-called negative control.
- David Saikin and Ensis01
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1 hour ago, AMcCord said:
We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time
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Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well.
Excellent use of your "abundant spare time" !
On a more serious note, analysis of this kind of data could lead to modifications in typical practice and result in efficiencies of time and money (and, ultimately, patient care/outcome). However, if the ultra-bean counters get hold of this issue, there's a very good chance that they will find, and put administrative restrictions on all kinds of "unnecessary testing". I appreciate that medicine evolves, but sometimes the appropriate approach has already been identified.
- AMcCord and Malcolm Needs
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19 hours ago, pbaker said:
Does anybody have any data regarding how many of the type and screens ordered by the ED actually get blood products? Those products could be given in the ED or on the floor after admission.
One of my ED docs is trying to determine if they are requesting type and screens appropriately. I did a 3 month retrospective review of data and only 28% of the type and screens ordered by ED actually got transfused from that specimen. Doc wants to know if that is good or if they are ordering too many type and screens.
Thanks,
This is a very interesting question. I suspect that many, many, many tests requested by the ED (A & E) could be categorized as "unnecessary" during analysis in the quiet time after "The Storm", i.e., the results had no relevance to the patients' treatment. But, in the moment (especially, during trauma), the medics have very little idea of what clinical data is important at that time. A "shotgun" approach seems to be appropriate. I'm not sure there is a way to meter or control this process (other than having extremely savvy ED staff). It seems to be a necessary evil - the need for rapid turn around overweighs the concern of "over-ordering" tests.
And, as Malcolm says, a little extra time for the BB to do its work is always appreciated.
- Ensis01, jshepherd and John C. Staley
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22 hours ago, Baby Banker said:
They've never been positive.
That made me think. I must have done many hundreds of elutions and have never seen reactivity in the last wash. Perhaps I was just lucky. I assume someone on this Forum has encountered reactivity in the last wash. Anyone care to share their experience(s) ? What were the circumstances ? What was the patient's diagnosis ? How did you resolve the issue ?
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14 hours ago, Ensis01 said:
Never yet seen a color photocopier at any place I have worked
Our machine is a combo color printer/photocopier/scanner. Just like most "multi-tools", it's OK, but doesn't really do all of its tasks exceptionally well. Grey shading often comes out bluish and when it scans colored materials, the colors are badly translated. Ho-hum, First World problems.
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1 hour ago, Ensis01 said:
I like the not black or red ink logic; all other colors clearly indicate an original document and not a photocopy. As long as it is permanent and waterproof any other color or shade of ink works. I personally like weird blues
I agree. I like the blue ink option because it used to be an obvious indication that the document is the original. Now, with color photocopiers in widespread use, I have to double check. Sneaky !
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1 hour ago, pbaker said:
We use the Elu-Kit to for the elution and perform tube testing with no additive.
Was the Antibody Screen also performed in "the tube" ?
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Very interesting. May I ask what assay/test is being used to detect the antibody ? Tube (with or without additive), gel, solid phase ?
And, may I presume that the anti-P1 is believed to be the the cause of "the hemoglobin has been dropping even with transfusion." ?
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Interesting discussion. Yes, cardboard can carry dirt and/or insects, but to imply that the presence of such on supplies like saline cubes creates a risk to patients and staff is an extreme stretch. We don't live in a vacuum and most of us spend time outdoors with the dirt and bugs every day (potentially bringing them inside with us). A wipe with a damp paper towel should be sufficient to clean an obviously soiled outer container.
If you talk to the manufacturer of the saline, I'm sure they would argue that the outer box is not merely a convenient shipping container, but also an integral part of the product itself, designed to support the flexible primary container and get the best performance from the product. After all, they've designed in a nice little tear-out section that creates a perfect hole for the spigot/tap.
- Ensis01, donellda, John C. Staley and 2 others
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On 4/29/2022 at 11:30 AM, David Saikin said:
When you say assay, that is, to me, a test, like Type and Screen. Yes, we are using the same reagents but they are being used differently (automation vs manual). Your QC in this instance validates the entire test system.
But, but, but....you said "We QC the reagents". The equipment/instruments are qualified and deemed functional through calibration/certification/validation, and presumably, preventative maintenance.
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1 hour ago, AuntiS said:
In Canada, our standards also add a requirement to clearly labelled/segregated area:
CSTM 3.2.1.7
Contamination of blood components or blood products from patient samples, reagents and/or tissue products shall be avoided by ensuring that blood components and blood products are stored in designated storage equipment or in clearly labelled segregated areas within the storage equipment.(See guidance statement below:
Physical barriers are needed to prevent contamination of blood components and blood products from other materials stored in the same equipment or area.
Examples of physical barriers include a leak-proof shelf or container (preferably with a lid), clearly labeled to reflect the contents. If the physical barrier is a shelf, blood components/products should be stored above any potential contaminants (reagents, patient samples, etc.).)sandra
Very interesting, Sandra. I completely understand the intent of the regulations and I appreciate that first impressions of cleanliness of blood products are important. However, it appears that in an arguably overzealous attempt to keep everything "clean", the fact that the outside of any blood bag is not sterile is completely overlooked. The air to which the exterior of blood products are exposed (refrigerated or room temperature) is not sterile. But....this is not relevant because the product inside the bag is supposed to be sterile and appropriate precautions are used during infusion events.
That being said, I like a clean, orderly and well-labeled refrigerator !
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Please forgive my ignorance.....but do the regulations require facilities to "perform QC" on the reagents or the assay ?
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16 hours ago, L.C.H. said:
OK, follow-up as promised with results of the D chip - and I have some reading up to do on these.
Overall predicted RhD phenotype: D+ (weak partial)
Alleles:
- RHD*weak partial 4.0 encodes p.201Arg and p.223Val
- Hybrid RHD*D111a-CE(4-7)-D does not encode D but encodes partial C as part of r'S haplotype
The report includes a reference: "Experience with RHD*weak D type 4.0 in the USA," Blood Transfusion 2018:6: 1-3.
Presumably predicted to be V-VS+ ? Might want to check on the hrB status, too.
Repeat of donor Antigen typing
in Transfusion Services
Posted
Lots of users on this Forum are in the same place and I'm sure they have some good advice on how to approach this issue. However, I would be cautious of implementing an optional process that potentially calls into question the quality of previous work.