Uncrossmatched issue...

[lauried01]

Hi everyone- I am kinda new to the board, but I would love everyone's input on this issue. We had a pt. last weekend- ER ordered 2 O Neg UNXM'd- we prepared the 2 and sent 'em down. When I was doing the record check (in preparation for a sample), lo and behold, the pt. was an A2B with Anti-c (a real holy crap moment:eek:). Of course, the units were transfused with the rapid infuser, so it was too late by the time I called ER (and given the condition of the patient, the doc woulda probably wanted them anyway). We got our TS pathologist involved immediately, to help manage the patient. The screen was 2+ positive w/ the R2R2 and the rr cell, and of course both units were incompatible. The patient never appeared to have a trn rxn and the DAT was only ever microscopically positive. Obviously, there was this big investigation by our Medical Director and QA coordinator- there was nothing we could have done any differently (per our procedures) to have prevented this from happening.

My question is this- do any of you out there have anything in place to try to minimize the risk of this happening? We all know this is exactly why we have the docs sign off on UNXM'd units, but if there is a way to improve this process, I'd love to hear it. We currently do not have our Blood Bank package functional, so everything is manually done- we are required to have our unxm'd units to the ER w/in 5 minutes of the request. Do any of you actually take the time to do a record check before issuing UNXM'D? We were thinking of having a list posted of "problem patients" (much like the list in the store of bogus check writers)- it would be quite a long list, though.

Thanks-

Laurie D.

[CUMC]

Record checks are not done in our trauma center on doe patients.

They are entered into the system as doe--and combined later.

Treat the trauma first

[lauried01]

I totally agree. This patient wasn't a trauma, but a GI bleed- we had an ID on her (as opposed to Doe pt.), but our procedure is the same- treat the immediate need first, ask questions later. I guess it's just a chance we all take, but it is still quite unsettling to realize we have given incompatible blood.

[Likewine99]

Your BB delivered the standard of care regarding issuing un-xm'd units, albiet that they were incompatible after the fact.

I once had a trauma surgeon tell me that when patients are in dire need of blood the fact that they have antibodies is secondary to treating their massive blood loss.

The blood is passing through the pt so fast that there is hardly time for an ag/ab reaction to occur and that during a massive bleeding situation the pts immune system is often suppressed because the body is working to survive the massive bleed.

You do the best you can do in the emergent situation, we would have acted in the exact same manner as you did. It doesn't appear that the patient suffered any adverse affects from the incompatible blood, it's a risk we take in the massive bleeding situation.

[Lcsmrz]

Our ER Release procedure contains a history check (if the name/MRN is known), but I'm not sure the outcome would have been any different. If blood is needed now, it's needed now. Death by exsanguination is not an option.

At least the clinician and pathologist would have been making knowledgeable decisions about limiting transfusion of incompatible blood and proper monitoring afterwards.

[lauried01]

Yeah- as a matter of fact the ER doc was wanting MORE uncrossmatched even after she was aware that the patient had an antibody to a relatively high frequency antigen. It was at that point we gave her the number for our path, so he could help her understand the problem (They don't understand that O neg doesn't mean a total lack of antigens). We were also lucky, and able to find some c neg, E neg units within an hour.

I personally feel we did the best we could in the situation, but it is the fact that we had to defend what we did to the powers that be. Or, that it was some error on our part that allowed this to happen- we all know it is an inherent risk in giving emergency issue blood.

Thanks for the responses- aside from delaying patient care further by doing a record search, we could not have done anything differently- the doc probably would have wanted to give them anyway, and manage appropriately.

Laurie Davis, MT(ASCP)BB

[jhaig]

I had a situation very similar to this just recently. A patient came to the ER actively bleeding from esophageal varices and received 5 units of uncrossmatched O neg. It just so happened that he had a history of anti-Jka and three of the units transfused were (eventually) typed positive for Jka.

We monitored the patient for a possible transfusion reaction, but nothing ever happened. He probably went through such a large volume of blood that there was no time for a reaction to occur.

The priority is getting the patient volume, either by packed cells or crystalloids. Transfusion reactions can be dealt with once the danger has passed. It never feels right for a blood banker to give out least-incompatible or known incompatible blood, but sometimes you gotta do what you gotta do to save a patient's life.

[lauried01]

Thanks for your replies- it just reinforces that we acted more than appropriately.

Have a good day everyone!

[John C. Staley]

It is truly amazing how often incompatible blood to atypical antibodies is transfused with no ill effects to the patients.

The biggest concern is ABO, get that compatible and most of the time everything else works out OK!

:raincloud

[Eagle Eye]

There was no reaction at all??? Did the hemoglobin dropped? bilirubin elevated? How is the kidney funtion tests? Post specimen was not hemolyzed? DAT may be only microscopic postive because patient hemolyzed both units so fast...

If we have a record we need to check patient's record(we have computer and computer will flag that patient has anti-c)....I guess if you check the record you can take a chance and give Rh Postive unit.

We had a once a GI bleed patient with history of anti-C & anti-s and they called for 4 unit unxmatched when patient was coded...we took a chance and gave 4 RH negative units (all were C- and two out of 4 were s-)..

[lauried01]

Nope- she never showed any evidence of hemolysis whatsoever. We figured it just was due to the fact her body was too "preoccupied" with her current condition to worry about the incompatible units. We were also surprised- she also received 4 c-neg, E-neg units, and quite a bit of fluids within a few hours- dilutional perhaps (or maybe she just bled them out too quickly?)?

Yet another argument for getting our computer system up and running- it is quite cumbersome to do a record check as things are now- card files, old computer system lookup- it's insane! We are required to have those units to the ER within 2-3 minutes...

[jhaig]

For traumas we have 2 units of designated, uncrossmatched O neg in the fridge. In a trauma, we grab the units, an emergency release form for the doc to sign, and we're off to the races (our ER is two floors down and no pneumatic tube system). So far my best time is 47 seconds:cool:

If somebody is bleeding out so bad that they need an emergency transfusion, the doc's not going to be worried about antibodies anyway. Antibodies concerns are secondary to keeping the patient alive.

[Eoin]

There is often no time for a record check. (Varices, PPH, Ruptured aortic aneurysm etc). Many years ago, a transfusion specialist told us - you can always treat a patient with a T/x reaction - you can't treat an exanguinated patient!

If you had checked the record what would you have done? Whatever it was would delay provision of blood - unless you have a big stock of typed blood.

[Fizzbin]

Although the patient's BBK history would surely cause your heart to skip a beat, it is no different than if she was positive for Kell or Duffy; it's the chance anyone takes when transfusing uncrossmatched blood.

[Mabel Adams]

In the world of liver transplants I have heard that they "save the best wine for last" for patients with multiple antibodies for whom it is impossible to get sufficient quantity of antigen negative blood. Some of the text books even suggest giving the first couple of units as antigen negative, then a bunch of unmatched or partially matched units and try to fill them up at the end with compatible blood. Sometimes it is hard to get the info on when they are 6-10 units from the end.

There was a write-up on a CAP survey that I had around for years lining out this approach. Honor the ABO and maybe any Kidd antibodies, but otherwise it said that even incompatible blood carries oxygen.

[geekay]

Hi everybody,

I agree to the fact that in this instance, Blood Bank had done their best as per protocol and was not to be blamed !

But my way of thinking was different !

With so many senior and experienced people around , I had expected somebody to come out with a solution which can prevent such instances for the future , because I believe in the saying "an ideal Blood Bank personnel anticipates the problem and prevents it , rather than waiting for the problem to occur"....

By seeing the replies, am I to believe that we are stuck here without any solutions ? in emergency situations, "issue the blood and hope for the best"..is it ?

wishes to all,

engeekay2003

[Barb Thompson]

We had a similar case a few years ago.....cancer patient in the ER, hgb was 4. The ER dr ordered 2 units emergency release....we had a history on her, but 3 weeks prior she had a negative screen. Now she has anti-Jk(a), identified after both units were infused (later tested and found to be Jk(a) positive). Her serum turned brown. Her DAT became positive (IgG and C3), but was negative less than 12 hours later. She developed acute renal failure, and 4 days later, I saw her obituary in the paper (our patients never die, they are only "discharged", and we in the lab never know where they go). Her death was attributed to the cancer, but I often wondered if we hastened her demise.

[John C. Staley]

Hi everybody,

I agree to the fact that in this instance, Blood Bank had done their best as per protocol and was not to be blamed !

But my way of thinking was different !

With so many senior and experienced people around , I had expected somebody to come out with a solution which can prevent such instances for the future , because I believe in the saying "an ideal Blood Bank personnel anticipates the problem and prevents it , rather than waiting for the problem to occur"....

By seeing the replies, am I to believe that we are stuck here without any solutions ? in emergency situations, "issue the blood and hope for the best"..is it ?

wishes to all,

engeekay2003

Tell you what, you come up with the solution and I will certainly consider it. There are too many variables in the real world for us to account for every one of them. There comes a time when you need to forget the perfect world and do the best you can under the circumstances.

We are working within biological systems in which everyone is a little different and "always" and "never" should not even be in our vocabulary. Some problems simply do not have reasonable solutions under certain circumstances. I have came to realize this many years ago and the stress levels dropped considerably.

:surrender