Transfusion Reaction Workup

[keathwade]

Our transfusion reaction workup standard has been to do a clerical check, dat, and visualization of serum or plasma for hemolysis. If these are negative, then the workup is signed out as "no evidence of hemolytic transfusion reaction" and no further workup is done unless some unusual circumstance or finding is present to suggest something else be done. It is fortunate, I think that it is rare that any of the first-tier studies are positive and the workup is virtually all the time limited to the first tier studies.

One observer at our laboratory has voiced an opinion that in virtually every transfusion reaction workup, this limited workup is not adequate, and that every workup should include pre and post total and direct bilirubin, LDH, and haptoglobin as a minimum. This observer feels that the current standard of care requires these tests be added to the first-tier battery of tests.

Could members of this forum comment on what your standard first-tier testing consists of, and how often you find that you add more tests when the first-tier tests are negative?

Thanks for your input.

and

Happy New Year to all on the Blood Bank Talk forum!

Keath Wade

[Lcsmrz]

One has to ask the question, "How much is enough?". I can think of several other tests that may have some value, but when you look at the predictive value, it's quite low. And if you transfuse a couple old units, the suggested four tests may be slightly suggestive of hemolysis, so determining a cutoff would be interesting.

The clerical check has got to #1, the post DAT #2, and a visual check as #3 to catch those situations where #2 will be falsely negative due to destruction. These rule-out immediate hemolysis, and you can decide after that on clinical findings if additional work is warranted for situations of decreased survival.

[Mabel Adams]

I think CAP started requiring a repeat ABO on the post sample in the last couple of years, regardless of the nature of the reaction (other than allergic).

[Eagle Eye]

CAP requires ABORH & Antibody screen on POST specimen....Some STATE(eg. NJ) requirement is same as CAP.

[John C. Staley]

"One observer at our laboratory has voiced an opinion......"

I'm curious, who was this "observer" and what did they base their opinion on?

For everything but hives, we do a clerical check, a hemolysis check and on the post transfusion sample a DAT and ABO/Rh. If any of these are of concern the work-up gets real interesting. Otherwise we're done.

Oh yeah, for certain things we will also do bacterial studies but that is another story.

[SMW]

Beginning with the 22nd edition of the AABB Standards (effective 11/1/03) for a possible hemolytic reaction, a repeat ABO group determindation shall be performed on the posttransfusion sample, i.e., as part of the "first-tier" of testing.

[keathwade]

I did neglect to mention the repeat type and screen, which is part of our first-tier testing.

I was curious to see if any tranfusion services were going beyond the required testing as a routine. We have an opinion on the table that we are below the standard of care by doing only the Standards required testing in most cases, and so I wanted to ask how others feel about this. Also how often you find that clinical circumstances warrant additional testing, even when the standard initial testing is all negative?

Thanks for the responses. It is very nice to find this blood bank discussion group.

Keath Wade

[jhaig]

If you're meeting the Standard's standards, then there shouldn't be an issue.

We do a clerical check, hemolysis check, and pre-/post- ABO/Rh and DAT. The doctor always has the option of ordering a haptoglobin, urine dipstick for bilirubin, blood cultures, etc. but they're usually satisfied as long as the inital workup shows no discrepancies.

I wonder if this 'observer' is a chemistry tech trying to boost testing volumes:cool:

[ADA APONTE]

Our transfusion reaction workup standard has been to do a cleical check, dat, and visualization of serum or plasma for hemolysis. If these are negative, then the workup is signed out as "no evidence of hemolytic transfusion reaction" and no further workup is done unless some unusual circumstance or finding is present to suggest something else be done. It is fortunate, I think that it is rare that any of the first-tier studies are positive and the workup is virtually all the time limited to the first tier studies.

One observer at our laboratory has voiced an opinion that in virtually every transfusion reaction workup, this limited workup is not adequate, and that every workup should include pre and post total and direct bilirubin, LDH, and haptoglobin as a minimum. This observer feels that the current standard of care requires these tests be added to the first-tier battery of tests.

Could members of this forum comment on what your standard first-tier testing consists of, and how often you find that you add more tests when the first-tier tests are negative?

Thanks for your input.

and

Happy New Year to all on the Blood Bank Talk forum!

Keath Wade

IN OUR LAB WE DO EXACTLY WHAT YOU ARE DOING. WE ONLY CHECKED FOR CLERICAL ERRORS,DAT AND INSPECTED THE SERUM FOR HEMOLYSIS, THAT IS WHAT THE AABB ASK YOU TO DO.

[ADA APONTE]

IN OUR LAB WE ARED OING EXACTLY THE SAME, THAT IS WHAT AABB ASK FOR. ( EXCUSE MY ENGLISH ). WE HAVE NOT HAD ANY COMPLIANCE WITH OUR REGULATORY AGENCIES TILL NOW.

ADA ( P uerto Rico)

[Karen Olsen]

We are doing as most have already indicated - just what is required by regs and then only doing additional testing if indicated. I would like to ask if everyone is performing these clerical checks and initial testing for reactions only to Red Blood Cells or for all blood products? I am also wondering if anyone has added anything for TRALI. What initial indicators are used to cause suspicion of TRALI? I have read MANY articles and it all sounds great - but in practice what are people looking at initially to cause you to look further?

Thanks

[ADA APONTE]

We are only performing tihs for our RBC and if the signs and symptoms suggeted a suspected hemolysis reaction . If the patient only had chills or rash or other minor sypmtoms withouth fever we do not perform this workup.

[keathwade]

Thank you to all the knowledgable blood bank talk participants.

[keathwade]

Thanks for all the responses. This is very helpful. I think that I have found that our current procedure and routine is within the "mainstream" of current laboratory practice. It is a good thing when questions like this arise. It allows an opportunity for a review of a particular aspect of our practice, where we can reassure ourselves that our current procedures are optimal and/or find some aspects of what we are doing could actually be improved. I was glad to find the bloodbanktalk forum!

Thanks again.

Keath Wade

[GilTphoto]

CAP requires ABORH & Antibody screen on POST specimen....Some STATE(eg. NJ) requirement is same as CAP.

I have never seen any requirement for post antibody screen from CAP, unless post DAT is positive or hemolysis is present.

We just had our CAP/AABB inspection in October.

We do clerical check, pre and post ABO+Rh, DAT, hemolysis and icterus check. ABO+Rh and DAT on unit too. We only go further if any of these are positive.

I have a question though. Does anyone check the ABO on FFP or PLT's by doing a reverse with A1 and B cells?

[ADA APONTE]

We use to check the ABO for FFP doing a reverse but right now we are not doing it anymore.

[Packer Banker]

Posted twice- sorry. Just look at my number of posts, and I suppose you'll understand...

[Packer Banker]

In addition to clerical checks, we do

Pre: Visual check, ABO/Rh, hgb, DAT or auto control

Post: Visual check, ABO/Rh, hgb, DAT, urine hgb (& urine RBC if positive)

BTW, I realize this is not the issue here, but are the non-1st tier tests billed out separately? I can't imagine a haptoglobin cost being recovered. I don't know that we're even getting our hgb & urine testing paid for...

Hope your mind's at ease about the extra chemistry testing--

[cmiller]

We perform a clerical check on sample, unit, and transfusion slips. We perform visual inspections for hemolysis, ABO/Rh and DAT on pre and post samples. We also test a post urine for hemoglobin.

Negative results are forwarded on to our Medical Director for interpretation. If there are any positive results (excluding pos urine hemoglobin) that indicate a hemolytic reaction, we immediately notify our Medical Director and continue with additional testing.

I have only been working at my present job for ~5 years, but I have been told we have never had a reaction progress to phase 2 testing.

[Eagle Eye]

I have never seen any requirement for post antibody screen from CAP, unless post DAT is positive or hemolysis is present.

We just had our CAP/AABB inspection in October.

We do clerical check, pre and post ABO+Rh, DAT, hemolysis and icterus check. ABO+Rh and DAT on unit too. We only go further if any of these are positive.

I have a question though. Does anyone check the ABO on FFP or PLT's by doing a reverse with A1 and B cells?

We do not retype(reverse type) on our FFP & Platelet.

[DANDERS]

We do exactly what you do - clerical check, visual check for hemolysis and a DAT on the post sample. We also never have to go any further with our testing. Our pathologist signs off on it and could request any additional testing.

[DeeMc]

Hi everyone,

This question does not quite follow the thread but is related to transfusion reaction workups. What transfusion related symptoms do you list in your procedure to initiate a blood culture being obtained from the unit? Does everyone still include a gram stain as part of their procedure? I have been told by my microbiologist that the automated blood culture process is more sensitive and a gram stain is not necessary upon collection. My FDA inspector was not so sure....

[Seveets]

We will do blood cultures x2 on the patient and culture the blood bag with grams stain if the transfusion reaction includes the patient temperature going up + 3.5 degrees

[KKidd]

At the suggestion of an inspector we also added a gram stain and culture of the unit involved to our first tier of testing. If the post DAT is positive, we perform a pre DAT beforme deciding to perform second tier.

[LaraT23]

Our workup includes clerical of course, and post ABO. We also do post DAT, which if pos, we do a pre dat. We do not do an LDH or bili unless the post DAT is pos.