exlimey

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.

It's highly unusual, to put it mildly, to worry about antibodies to Lewis antigens. What's your institution's logic for this approach ?

Excellent point, Ensis01.

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.

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.

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.

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 ?

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.

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 !

Was the Antibody Screen also performed in "the tube" ?

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." ?

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.

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.

Thank you, David. As I suspected. So why do two test systems using the same lot numbers of reagents need to be subjected to daily QC ? Let the debate begin.....

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 !

Please forgive my ignorance.....but do the regulations require facilities to "perform QC" on the reagents or the assay ?

Presumably predicted to be V-VS+ ? Might want to check on the hrB status, too.

My sympathies, Darren. That's a horrible situation. It's generally accepted that the best way to minimize HUMAN error is automation (with the proviso that the systems are well designed). If a LIS allows post-dated entries, it would seem logical that "scanning" would be the best option to back-fill the missing data. And, probably a lot quicker. If one is forced to perform manual data entry, the process should probably include a second check (verification), preferably by a second individual. Either way, not fun for anyone. Good luck.

Some caution may be appropriate. Most "colds" are indeed clinically insignificant and mere laboratory annoyances. Most of these are autoantibodies that can be avoided by pre-warming methods. However, some can be clinically important - there are examples of anti-Vel that behave exact as LaurieD describes, but are IgM, cold-reactive alloantibodies that can cause serious in vivo hemolysis. I think one case reported by Jill Storry was actually fatal. Another nasty beastie in this category is anti-P+P1+Pk (anti-Tja, in the old vernacular). I would suggest that a Reference Laboratory take a look at the sample (the Blood Bank of Hawaii is close ), just to give some assurance that the troublemaker is "just a cold auto". Pre-warming without an antibody ID may be dangerous. Just my two cents.

To paraphrase Malcolm: A proven responder may have "other stuff", too. A serological crossmatch is probably the best, and sometimes, the only way to detect it.

All of the above are excellent suggestions. I will have to get up earlier to contribute.

From reading the previous comments, both old and new, it appears that the manufacturer (Ortho) does not specifically require the bubble and therefore nothing is in writing (the Directions for Use). You may be out of luck trying to find something to reference.

I find it interesting that various users have been told/advised to use a pipette in a manner that may compromise the accuracy of the volume delivered. I'm sure the pipette instructions indicate to use vertically. Thankfully, the serological assays that are used by the Transfusion Medicine field have a wide range of tolerance. The "1-drop to 1-drop" concept is horrifying to many other pathology disciplines.

Agreed. The initial results using the Screening Cells still need to be resolved. "Non-specific" probably won't be acceptable. Please clarify - "Screening cell is positive with 2 lines(2+)". Does this mean that one, or two of the Screening Cells are reactive?

Agreed. Anything less than a full phenotype is useless. We don't even do that for Screening Cells, which are arguably a lot more important.