Patient hx

[jack323]

What do yall do when a patient says they have antibodies and has no prior history? Antibody screen is negative and patient doesnt know which antibodies. Hx and screen was clear at the hospital the patient gave me. Would yall do a deep dive and call every hospital that the patient has been to. Or would you just extended xm

[Malcolm Needs ☆]

Extended cross-match, UNLESS, the history of which other hospitals the patient has been treated is known.

Of course, in the UK we have a national database of patient's antibodies, which makes life an awful lot easier, even if the data is just a "snap shop".

[jayinsat]

I agree with Malcolm. I would dig as deep as possible to find that antibody history. If none can be found, I would do AHG crossmatches. If it was a frequent antibody, the titers should rise to detectable levels soon.

[Neil Blumberg]

One additional approach would be to increase the sensitivity of the antibody screen by your preferred method (e.g., PEG, ± using enzyme treated red cells). Obviously increases the possibility of detecting pan-reactivity/false positive tests.  

[Malcolm Needs ☆]

2 hours ago, jayinsat said:

I agree with Malcolm. I would dig as deep as possible to find that antibody history. If none can be found, I would do AHG crossmatches. If it was a frequent antibody, the titers should rise to detectable levels soon.

The trouble is that, if the antibody happened to be an anti-Jka or, worse, an anti-Vel, the resulting rise in titre, following an anamnestic response, could be fatal on rare occasions.

[Malcolm Needs ☆]

1 hour ago, Neil Blumberg said:

One additional approach would be to increase the sensitivity of the antibody screen by your preferred method (e.g., PEG, ± using enzyme treated red cells). Obviously increases the possibility of detecting pan-reactivity/false positive tests.  

I would be wary of relying on enzyme-treated red cells, as a negative reaction could be due to the cognate antigen being denatured by the particular enzyme used.

[jack323]

38 minutes ago, Malcolm Needs said:

The trouble is that, if the antibody happened to be an anti-Jka or, worse, an anti-Vel, the resulting rise in titre, following an anamnestic response, could be fatal on rare occasions.

Im guessing since uk has a national database that this happens alot less. The usa should have something similar.

Is there statistics on anamnestic response? How often have you delt with it? 

 

[Malcolm Needs ☆]

48 minutes ago, jack323 said:

Im guessing since uk has a national database that this happens alot less. The usa should have something similar.

Is there statistics on anamnestic response? How often have you delt with it? 

 

I THINK there are figures in the earlier "Mollison's (but I am relying on a notoriously bad memory).  Personally, only a few (in 43 years), but there are figures  annually in the UK SHOT Reports (Severe Hazards of Transfusion).

[John C. Staley]

20 hours ago, jack323 said:

Im guessing since uk has a national database that this happens alot less. The usa should have something similar.

Is there statistics on anamnestic response? How often have you delt with it? 

 

The USA is considerably larger, we do not have a national healthcare system (which I personally hope we never have), and there is not a central data base that is accessible to all.  I'm afraid the cost / benefit analysis of establishing such would not favor attempting one.  Just my opinion.  

[Neil Blumberg]

Another thing to try to increase sensitivity (other than PEG or other enhancement) is to increase the serum/cell ratio in the screen/indirect antiglobulin test.  If there is no reactivity with enhancement, enzyme treated rbc (agree with Malcolm's caveat that some antigens will be destroyed) and increased serum/cell, one can be more confident there is nothing detectable pre-transfusion.  Some consolation at least ...

[Ensis01]

I have never encountered a patient that says they have antibodies unless they have a card. 

[Malcolm Needs ☆]

1 minute ago, Ensis01 said:

I have never encountered a patient that says they have antibodies unless they have a card. 

Believe me when I say that you are lucky!  

[Ensis01]

12 minutes ago, Malcolm Needs said:

Believe me when I say that you are lucky!  

Had a lot of hospitals saying patient has a Vel when they should have said V

[Malcolm Needs ☆]

49 minutes ago, Ensis01 said:

Had a lot of hospitals saying patient has a Vel when they should have said V

OMG!!!!!!!!!!!!

[Baby Banker]

On 6/5/2023 at 10:39 AM, Malcolm Needs said:

I would be wary of relying on enzyme-treated red cells, as a negative reaction could be due to the cognate antigen being denatured by the particular enzyme used.

I would not use an enzyme treated screen as my only method for exactly that reason.

[AMcCord]

18 hours ago, Ensis01 said:

I have never encountered a patient that says they have antibodies unless they have a card. 

We don't issue cards to patients with antibodies. I've discussed it with several of our medical directors, but none of them have been very enthused. They feel that most of the cards will be lost, forgotten about, or the info won't get passed on to us. Based on our past experience, I can't make a strong case. Our current medical director is a believer in Med Alert bracelets for the scary stuff.

I've seen only a few cards, under the following scenarios:

• A few times: nurse is checking out blood and says 'Oh, the patient showed me this card about an antibody or something. Did you need to see it?' YES, before you transfuse!
• Twice: nurse has started transfusion and calls Blood Bank - 'Mr XYZ showed me a card about an antibody or something today (or yesterday). Do you need to see it?' YES, STOP THE TRANSFUSION!
• and once, once only - as the patient was being admitted on the floor, the nurse called and said the patient had a card about transfusions - 'Do you want me to fax you a copy?' YES! Gold star for you!

Sometimes I wish we could put a chip in the scruff of everybody's neck that had all that info loaded on it - allergies, antibodies, med history - wouldn't that be handy.

[MAGNUM]

32 minutes ago, AMcCord said:

Sometimes I wish we could put a chip in the scruff of everybody's neck that had all that info loaded on it - allergies, antibodies, med history - wouldn't that be handy.

Jason Bourne all over again!!

[jayinsat]

50 minutes ago, AMcCord said:

We don't issue cards to patients with antibodies. I've discussed it with several of our medical directors, but none of them have been very enthused. They feel that most of the cards will be lost, forgotten about, or the info won't get passed on to us. Based on our past experience, I can't make a strong case. Our current medical director is a believer in Med Alert bracelets for the scary stuff.

I've seen only a few cards, under the following scenarios:

• A few times: nurse is checking out blood and says 'Oh, the patient showed me this card about an antibody or something. Did you need to see it?' YES, before you transfuse!
• Twice: nurse has started transfusion and calls Blood Bank - 'Mr XYZ showed me a card about an antibody or something today (or yesterday). Do you need to see it?' YES, STOP THE TRANSFUSION!
• and once, once only - as the patient was being admitted on the floor, the nurse called and said the patient had a card about transfusions - 'Do you want me to fax you a copy?' YES! Gold star for you!

Sometimes I wish we could put a chip in the scruff of everybody's neck that had all that info loaded on it - allergies, antibodies, med history - wouldn't that be handy.

I worked at a site that sent cards. Never did any good. For all the work there was no benefit. As for the chip...pass.

[Neil Blumberg]

We send cards to physicians (for their patients, if they like)  because it is our responsibility to patients, not because it works well.

If anyone has better ideas, please share them. Obviously a national database would be best.

Doing absolutely nothing is not an option from our standpoint.

[SbbPerson ☆]

On 6/8/2023 at 10:47 AM, Ensis01 said:

I have never encountered a patient that says they have antibodies unless they have a card. 

Several years ago, I met one patient with a card, She showed it to me when I drew her blood for a type and screen. I think she had Jka. She had no history and was visiting from out of town.  Her physician recommended for her to keep her card on her person.  First time I ever saw such a card. 

[Malcolm Needs ☆]

My own experience with an antibody card that would have been useful, from 2007.  Slides 5 and 25 are of particular interest from my own point of view!  It should be noted that I no longer work for the NBS/NHSBT, and am no longer entitled to put CSci FIBMS after my name, although I am entitled to put FBBTS after it.  Funny old world!

COADOA.ppt

Edited June 13, 2023 by Malcolm Needs

[AMcCord]

21 hours ago, Malcolm Needs said:

Slides 5 and 25 are of particular interest from my own point of view! 

OADOA.ppt 87 kB · 2 downloads

Especially slide 25  . 

[tricore]

 

Ask the patient if they have ever been admitted with another name. We had a woman going for heart surgery and she told the phlebotomist she had antibodies. I asked her where they had been identified. She said this hospital. We could not find any records. When the antibodies were identified she had been admitted with a different name. No computer then. Could not search by MRN. (Note: it does not help when they have been given a new MRN, happens more frequent than I like judging by the number of patients I had to merge when I was in IT.) We had to go to medical records and search the microfiche. She had 3 clinically significant antibodies. Sorry, I don't remember the specificities.

[Ensis01]

I once got a pre-surgery form where the patient initialed “never been transfused”. Our facility had given 5 RBC (over a two week period) three months previously. 

[Malcolm Needs ☆]

9 hours ago, Ensis01 said:

I once got a pre-surgery form where the patient initialed “never been transfused”. Our facility had given 5 RBC (over a two week period) three months previously. 

I know the feeling.  I once cross-matched for a patient who was a Jehovah's Witness who said that they had never been transfused.  The only trouble was that their serum/plasma contained one of the strongest anti-Fya's that I ever saw throughout my career!!!!!!!!