Please let me know what you think about this.
Recently we sent a unit to micro for a gram stain and culture. we do this for all the febrile transfusion reactions (>2 degrees F temperature rise). Micro called back and reported no organisms seen, no WBCs. After 24 hrs, they reported gram positive cocci in clusters. The next day the organism identified was S. aureus. My question is: how would you report the gram stain? Negative or positive? Some of us believe it should be reported as positive, other techs say we should go by the initial call and report it as negative. we informed the medical director and she contacted the patient's physician. Our disagreement is on how to report the gram stain in the computer.
Hope everyone has a great weekend!!
Sorry for the novel! I have an odd case that I wanted some input on.
Patient History: 66 year old female with CMML. A Pos, with a negative antibody screen, no history of clinically significant antibodies. Has HLA antibodies that have never been detected in our IgG antibody screen testing, but cause her to be refractory to random platelet transfusions. Has been getting HLA-matched platelets. She has received 9 RBCs and 24 apheresis PLTs over the month of September.
Transfusion Reaction: The patient received 1 O Pos HLA-matched apheresis platelet (Anti-A titer <1:200) on 8/29/16 at 1100, and 1 electronically compatible A Pos PCLR right after the platelet was done infusing. After the RBC infusion, the patient developed chills/rigors, flushing, and felt tired and "out of it" according to the RN. Her temperature had increased >2 degrees F, so a transfusion reaction investigation was initiated.
Clerical Check OK Gram stain on both the RBC and PLT were negative. Cultures from both are still pending. Post-Rxn Sample: ABO/Rh = A Pos Poly (IgG/C3) DAT = 1+ Positive Mono IgG DAT = 2+ Positive Mono C3 DAT = 1+ Positive Aby Screen = Negative Plasma color = slightly darker than Pre-Rxn sample, but not visably hemolyzed Pre-Rxn Sample: Poly (IgG/C3) DAT = Negative Aby Screen = Negative Gel/AHG XM of transfused RBC with Pre- and Post-Rxn samples = Negative/Compatible RBC unit DAT = Negative So, we obviously decided to perform an eluate on the post-reaction sample. The eluate was tested against screen cells, A1 cells, B cells, and panel cells, and showed no reactivity. Questioning the original eluate, we performed an eluate on a new post-reaction sample the next morning (8/30), and got the same results.
We decided to try running both eluates against the transfused RBC and the patient's own cells from the pre-reaction (DAT negative) sample. The eluate did not react with the transfused RBC, but reacted 1+ with the patient's Pre-Rxn sample.
How the heck do I explain this!?
Consider that a transfusion reaction workup has completed and no evidence of hemolysis was noted.
The medical director or designee has been contacted and provided their evaluation and further transfusion is acceptable.
If additional RBCs need to be issued for the patient do you...
Continue to use the original type and screen for crossmatching RBCs? Use the post-transfusion reaction specimen for crossmatching? Use the post-transfusion reaction specimen for crossmatching after it's had an antibody screen tested? Any orther sort of scenario?
We have an extensive initial phase transfusion reaction workup that I'm not entirely happy with:
Clerical check Visual inspection of infusion set/blood product Visual inspection for evidence of hemolysis DAT on post-specimen Post-specimen ABO/Rh and antibody screen IAT XM of RBC units transfused with post-specimen UA
I am in the process of updating our Transfusion Reaction Workup procedure. The current procedure is divided into 2 phases. Phase 1 testing consists of a clerical check, DAT (Pre and Post), visual examination of patients serum, ABORh retype of post-transfusion specimen and a visual examination of the unit and any solutions hanging with it.
If there are no clerical errors, visual inspection is okay, DATs are negative, and there is no drastic change in the serum/plasma we are to call nursing/physician with results and additonal units of blood may be issued for transfusion.
An administrator (fresh from a presentation of JACHO surveys) wants a statement added to the procedure stating the transfusion cannot be restarted unless the Medical Director approves.
????? I am looking for clarification about why the Medical Director would need to approve additonal transfusions if everything is negative.
(I think the physican should decide if additonal units should be transfused.)
If there are any errors detected, DATs are positive, or post transfusion is icteric/hemolyzed we would proceed with phase 2 of testing, notify the nurse and/or physician immediatly, and notify the blood bank senior tech or Laboratory Medical Director. The Medical Director/Pathologist review all transfusion reaction workups.
Thank you for your input!