Transfusion Reaction Workup

[John C. Staley]

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.

I'm curious, what justification did the inspector use for recommending always doing a gram stain and culture of the unit in your first tier of testing? Was this inspector CAP, AABB, FDA, State?

[KKidd]

I'm curious, what justification did the inspector use for recommending always doing a gram stain and culture of the unit in your first tier of testing? Was this inspector CAP, AABB, FDA, State?

This inspector was AABB. It was more of a strong suggestion and my manager decided to run with it.

[Eoin]

Look up bbguy.org . Very good from a medical point of view. We follow his lead, but with a staged approach.

Eoin

[sshel55]

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.

The key here is "for a possible hemolytic reaction" and if your clerical check, DAT and observation for hemoglobinemia are all negative then some would say you have ruled out an immediate hemolytic reaction. This question was answered in AABB Standards Source in 2005 where it says that "there is no reason to perform an ABO/Rh on a post transfusion specimen unless there is reason to suspect that a hemolytic reaction has occurred" and that "the evaluation and tests used to evaluate whether a hemolytic reaction had occurred could be defined by the medical director." In our facility the ABO is part of the tier II testing.

[Winter]

Our facility performs the clerical check, visual check for hemolysis comparing the pre to the post, DAT and ABO/Rh on post, test post urine specimen supernatant for hemoglobin (compare to pre urine results is abailable). If any are positive, we gram stain and culture the unit; repeat ABO/Rh on unit; repeat crossmatch and ab screen with pre and first post specimens; collect a 5 to 7 hr post specimen for repeat DAT and ab screen; assay all three for bilirubin; and check a 5-7 hr urine specimen for hemoblobinuria.

I am curious also about what others are doing for reactions to other components. Do you reconfirm FFP ABO if reaction is reported? Do you ever give O pheresed platelets to a non-group O? If a reaction is reported after such a transfusion, what would be the follow-up?

[Karen Olsen]

I am also very interested in what others are doing as far as reactions to components are concerned. Do you check for clerical errors,hemolysis and perform the DAT and ABO on post sample just as you would for RBC's?

[rcurrie]

I am with you, Ada. I never agreed with the CAP ABO repeat requirement.

I am still waiting on the pictures of your new blood center ;-)

BC

[mrstymt]

It's either our policies are asking for WAY too much, or at least I'd feel more comfortable with the "extended" TRW...

We do clerical, pre- and post- DAT, visual check pre and post, Type and screen pre- and post- (argh, that's a lot already!!), bag culture, first void urinalysis. And these are all on products, RBCs and platelets more common than others.

If it is febrile, we do 1 set blood cultures.

There is an outline for each step (like step 1, yes, continue, step 1 no? stop..) But basically we request all the samples at call of TRW and then we follow the outline. However, when we call the pathologists, they expect the Type and screen to have been repeated on pre and post regardless if the top 3 were negative for errors.

Now ask me if I agree with this.....someone in this thread already said that the PPV doesn't really make much of a difference from all this work. If our automated system is up, no problem, just load pre and post and done. If we're manual (like we are now since we've been having automation problems), it's quite a kicker. It takes you away from the other work you have to do.

Good luck!

[bbbirder]

The key here is "for a possible hemolytic reaction" and if your clerical check, DAT and observation for hemoglobinemia are all negative then some would say you have ruled out an immediate hemolytic reaction. This question was answered in AABB Standards Source in 2005 where it says that "there is no reason to perform an ABO/Rh on a post transfusion specimen unless there is reason to suspect that a hemolytic reaction has occurred" and that "the evaluation and tests used to evaluate whether a hemolytic reaction had occurred could be defined by the medical director." In our facility the ABO is part of the tier II testing.

This is the same as we do. If no evidence of Hemolytic reaction, no further workup (except for high fever, if the patient has experienced a fever of >102, we will usually culture the unit, regardless of other findings)

For FFP & PLT, we do same thing. Positive DATs after ABO incompatible PLTs are expected, the pathologist will expound on that in a consult.

Linda Frederick

[Mary Ann]

The chemistry tests are appropriate for a hemolytic transfusion rxn for monitoring purposes,not to be used as standard practice for every reaction with blood products.Our facility lists these tests for further investigation if needed,to be ordered by the pathologist. Thanks

[BUGGIE]

We do the same basic transfusion reaction workup on all blood products, including a blood culture on the patient and unit if there is evidence of a 2F/1C increase in temperature above baseline (initial temp reading). We recently had a CLIA/CMS inspection after our CAP inspection where the inspector found 2/9 transfused patient's charts with a > 2F increase in temperature and no transfusion reaction work up was done. This has caused a thorough investigation of transfusion reactions. We do have a Blood Bank new employee orientation and a Yearly blood bank Healthstream review for transfusing nurses and lab but this obviously was not enough as many nurses said they had never herd that a >2F increase in temperature could indicate a reaction. We now will have a Blood administration and reaction review at our anual manditory National Patient Saftey Goals fair that will be attented by all nursing and doctors giving blood. That should help a lot.

Is this common practice in other facilities to do work ups on all products and to do workups on temperature increases? Our blood bank seems to be the main inspectors for the transfusion records. We have a paper system that is reivewed for all times, dates, signatures, length of transfusion and now particularly temperature increases.

[ANORRIS]

Are most of you blood bankers calling reactions with a temp spike of 1degree F or 2 degree F?

[Deny Morlino]

To make it confusing it is 2 degree C we go by as that is taken directly from the ARC form used to report reactions to them. This is approximately 3.6 degrees F.

[Eoin]

Suspect Temp Rises are 1.5oC above the surrent baseline temperature.

Regards,

Eoin

[KKidd]

We use 2F from the base line. Anything less has to be ordered by the physician.

[Eagle Eye]

2F or 1C from the baseline regardless of temp.(normal Vs fever). We may change it based on Hemovigilance guidline.

[Mabel Adams]

All my experience in the US is using 1 degree C or 2 degrees F (not including raising temp to normal after cooling the patient for surgery). We have some wording that makes clear that the increase must put the patient into a range above normal. You might want to use the new CDC Hemovigilance definiitions as I assume they are going to become standard in the US.

[Karen Olsen]

We use 1 degree C or 1.8 degrees F.

[Stoogiesfreak]

Would like to introduce a slightly different topic on transfusion reactions. How does everyone handle blood pressure issues? Systolic and diastolic or only systolic or only diastolic? We have found all kinds of variations on how low or high to initiate a workup. Currently we are using 30mm/Hg drop in systolic to trigger a workup, but would like to change that to diastolic only.

?? Anybody doing anything like this?

Thanks,

John

[rravkin@aol.com]

We require ABO/Rh confirmation and a DAT on pre and post reaction specimens along with a post Urine speciman, in addition to the clerical check for the initial investigation.