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Please help me to get compatible blood ?


paulis

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I am lab technician and work in a hospial based blood bank in Vietnam. I have some difficulties and need your help. A patient need transfusion but we can not choose compatible blood for her although we have done X/M with all the blood bags in the stock ( about 50 bags) but all are incompatible with the patient's plasma AHG(+) . Patient with DAT(+), IAt (+), AC (++).

1.Please tell me how can I get compatible blood for the patient in this case?

2. In Vietnam, We do not perform Antibody identification for the reason of high cost , Do you have any solutions to solve this case?

3. We are advised to transfuse to the the patient with the small amount of blood. Is that right and acceptable?

Thank you very much.

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In my opinion, antibody identification must be performed. The patient probably has a warm autoantibody rendering every crossmatch performed to be incompatible. However, depending upon the reactivity at LISS IAT, adsorption must be performed to rule out underlying alloantibodies. An in vivo crossmatch may be all that is available to you; however, depending upon the severity of the patient's condition, that has significant risks. Good luck. I would vote for a workup!

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If your patient has not been transfused in the past 3 months you can try to absorb out the antibody using the pt's own red cells. Do you have access to ficin or PeG? Either can be used to make your autoabsorption more effective? Do you have access to a technical source? (AABB Technical Manual, John Judd's Immunhematology Methods manual . . . or some such? If yes, you should be able to find procedures in them to assist in your absorption - if not, email me and I'll give you a shortened version to try.

Your IAT is sufficiently weak so that you should be able to absorb out all autoantibody.

What technology are you using - tubes, gel, capture?

email is dsaikin@littletonhospital.org.

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I am lab technician and work in a hospial based blood bank in Vietnam. I have some difficulties and need your help. A patient need transfusion but we can not choose compatible blood for her although we have done X/M with all the blood bags in the stock ( about 50 bags) but all are incompatible with the patient's plasma AHG(+) . Patient with DAT(+), IAt (+), AC (++).

1.Please tell me how can I get compatible blood for the patient in this case?

2. In Vietnam, We do not perform Antibody identification for the reason of high cost , Do you have any solutions to solve this case?

3. We are advised to transfuse to the the patient with the small amount of blood. Is that right and acceptable?

Thank you very much.

The transfusion of incompatible blood bags is not really acceptable you can transfuse blood with a positive Antibodyscreen from the patient without identification only if the results of the X/M are negative!!

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Cornelia

Sometimes you have to transfuse incompatible . . . when there is an autoimmune, as this appears to be, you may get by using autoabsorbed plasma/serum, but in reality, using your neat specimen, it is going to be incompatible. Also, sometimes you have to give incompatible units because exsanguination is more unacceptable. This case is not a black and white antibody - as intimated above, it appears to be autoimmune.

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Ummm ... there are limited resources in the BB in Vietnam ... let's shift our thinking patterns here.

I agree with David S. and those who say 'give it and see what happens' but only IF the transfusion is life-saving. To transfuse a patient with an auto-immune process such as this can be counterproductive ... it is best to treat the problem not the symptoms.

As far as an 'in vivo crossmatch' ... that only works if there's a 'immediate' hemolysin, eg. ABO or ... gee, I can't think of any other! This solution hurts my teeth ...

Again, I agree that this is most likely an auto-antibody. Yes, ordinarily we'd chase down what 'could be under there' ... but she's not in one of our hospitals where we have 'unlimited' testing resources. Here's where history comes in ... if the patient has never been transfused (or pregnant, albeit that immunization is low) then we do not expect any clinically significant antibodies under there.

It doesn't mean the transfusion is 'safe' or will be uneventful, though ... transfusing a patient with an autoimmune process has it's inherent risks, one being the it can exacerbate the original problem [ie. the cause of the DAT]!

My first choice would be to withhold transfusion and treat the real problem, that is the cause of that DAT and autoantibody.

Buuut ... if you MUST transfuse, then transfuse with small amounts of incompatible blood (ok, choose 'least incompatible' if it makes you feel better) and monitor the patient for symptoms of overt adverse reaction ... keeping IV lines open and plenty of fluids running ... for a few hours post transfusion. (To sample for hemolysis may make the BB feel better, but unless the antibody causes immediate overt hemolysis, no color change will be seen in the plasma. Likewise, don't expect a DAT rise ... it's too small of a volume of RBC's to change the DAT grading.)

I also agree ... a delayed hemolytic reaction is a lot easier to deal with than death.

Just be sure that's the real risk ...

I highly recommend medication for the cause of the autoantibody, not transfusion for the low hct values.

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  • 2 weeks later...

In case it isn't clear from this discussion, an in vivo crossmatch is as described above where a small amount of the unit is transfused and the patient observed for signs of reaction. Drawing a sample from the patient before continuing the transfusion and spinning it down to look for hemolysis could rule out overt intravascular hemolysis, but not all incompatibility--especially when dealing with an autoantibody.

Treatment of autoantibodies in this country (USA) is usually with steriod drugs to reduce the production of the autoantibody and the destruction of the patient's own red cells. I have seen a patient with a 4 g/dl hemoglobin recover nicely without transfusion. She had a reticulocyte count of about 13 (~10 times normal) so as soon as destruction of her red cells slowed, she made enough red cells to bring her hemoglobin up to 7 or 8 in just a few days. I think most other countries report hemoglobins in other units so the number is 10 times what I listed above.

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Mabel Adams,

Thank you for your new-to-me information . I admit that I have not heard of treatment of autoantibodies. I think it is the helpful information so that I should have a discussion with treatment doctors in my hospital. Do you have any reference books or documents on the treatment of autoantibodies? Please email to dghoanglong@gmail.com. Thanks.

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http://www.nlm.nih.gov/medlineplus/ency/article/000579.htm

Try the above link for a simple start. You might find Medlineplus.gov a good place to start with many medical questions. It is a collection of reputable medical sites in the US compiled by the National Library of Medicine. It is intended for non-medical people to learn about health conditions from trustworthy sites. By clicking on "Other Resources", then "Medline/Pubmed" you can search a database of medical journals and at least get references and often abstracts. Sometimes you can read the whole article.

Maybe the following reference will refer to the older therapy as well as the new drug being discussed. Otherwise, any textbook on clinical hematology should have some reference to it.

1: Am J Hematol. 2005 Feb;78(2):123-6.http:--www3.interscience.wiley.com-aboutus-images-wiley_interscience_150x34.gif Links

Two cases of refractory warm autoimmune hemolytic anemia treated with rituximab.

Ramanathan S, Koutts J, Hertzberg MS.

Department of Haematology, Westmead Hospital, Westmead, NSW 2145, Australia.

Autoimmune hemolytic anemia is thought to be mediated via auto-antibodies produced by lymphoid B cells. This may be an idiopathic process or secondary to an underlying infection or lymphoproliferative disorder. Conventional treatment comprises immunosuppression with corticosteroids and, in some cases, splenectomy. A proportion of patients require lifelong immunosuppression to maintain disease remission. Monoclonal antibody rituximab has gained widespread acceptance in the management of B-cell malignancies. Additionally, it has been used to treat disorders associated with auto-antibody production, such as cold hemagglutinin disease, immune thrombocytopenia, and Evans syndrome. Its use in the treatment of patients with autoimmune hemolytic anemia in the setting of allogeneic bone marrow transplantation as well as in patients with an underlying lymphoproliferative disease has also been reported. We report herein the successful use of rituximab in the treatment of two patients with idiopathic refractory warm autoimmune hemolytic anemia, who are still in remission at 15 and 9 months following treatment. Copyright 2005 Wiley-Liss,Inc.

PMID: 15682420 [PubMed - indexed for MEDLINE]

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As an interesting side note to this discussion, we had a sickle cell patient earlier this year who had multiple alloantibodies, then developed a warm autoantibody. We gave him blood that was negative for all of the allos (we did an absorption to detect any new ones) that was "compatible" with absorbed plasma. He destroyed everything we gave him and began a rapid destruction of his own cells in the process. He got down to a 1.9 hemoglobin before they got him stabilized and the doctor fussed at me for not providing compatible blood. I told him it was his decision to transfuse based on the clinical situation, but it looked to me as though anything we gave this patient would push him over the edge. The doctor took my advise and avoided transfusion. The patient lived through the experience. I hope we never have to transfuse him again, but since he is a sickle patient, that is almost certainly a forelorn hope.

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We had a warm auto patient at my prior workplace that they transfused and she started to hemolyze more actively and died. The doc said there were some other unusual things about that patient but it was enough to make a believer of me that transfusing warm autos occasionally "ramps up" the hemolysis and it is worth making sure the doc is aware that is a risk when he signs what is often considered a rather routine release form.

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I have been working on a similar release for crossmatch-incompatible units for our WAA patients. Now, I am being told by our Patient Quality Care/Safety person that this form is all wrong. She seems to think that the release should not be to ensure that the doctor is aware of the risks and accepts responsibility, but rather re-phrased into layman's terms to inform the patient of the situation, and then have the patient sign accepting responsibility. She says that the physician, because he has an MD after his name, is already fully aware of the nature of WAA, and does not need to sign any sort of release. Has anyone else run across this? I've been pondering this for a couple of weeks, and have yet to come up with a simple way to explain a WAA in a sentence or two (or even a paragraph or two) that explains the situation well enough for the average person to make an informed, educated decision to accept the blood. I would appreciate any input on this.

Karen

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Ask your QA person to poll 5 doctors about WAA and have her report the results to you. ;) I bet your average hospitalist would be hard pressed to tell you what our different test results mean. I bet a fair number of them would be grateful for us providing them with additional info.

Hematologists are pretty knowledgeable but they have so much experience with transfusing warm autos with no repercussions they probably forget about this risk.

Wow, do they expect the patient to decide whether to put in a heart stent or to do an open vs. laporoscopic abdominal surgery too? I think that is practicing medicine without a license!

Info for patient: You have an autoimmune problem that is detroying your own RBCs. If we transfuse you it will also destroy the transfused cells, maybe at the same rate as your own, or maybe it will increase the rate of destruction. Only rarely does it make the destruction so much worse that it becomes life-threatening. If we wait to transfuse and treat you with drugs instead, you may have an increased risk of cardiac arrest (for Hgb < 7) but we aren't sure because those studies weren't done with patients with your illness. Otherwise, you just will have the symptoms of anemia. If you do get worse while waiting for the drugs to work, you could always get a transfusion then. The drugs should start to make some improvement in your anemia in a day or two. Of course, this all depends on whether you have a bad heart or bad kidneys that might either be damaged by the hypoxia or might increase the risk of circulatory issues. (Depending on our testing) You also may or may not have antibodies to other people's red blood cells (blood donors) that will make them incompatible in your system. This incompatibility may be less or greater than the autoantibody destruction. We can't be sure. If it is severe, the consequences can be a collapse of your blood clotting system, kidney damage or failure and even death. Every patient reacts differently.

This is partly tongue in cheek and I am sure I have forgotten key points that would need to be in a real patient consent form.

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Again, I agree with David. Informed Consent is required ... but who is supposed to provide the 'Informed' part? At our hospitals, the physician is given that 'burden'. So, to be consistent here, it is the physician who gets the additional information and he/she needs to figure out how to relay all this to his/her patient. Some risks are simple, some are more complicated.

Documentation of informing the physician of additional risks such as outlined here is a good idea from a liability point of view ... don't want physicians claiming in court that they were not informed of the increased risks.

However, I don't agree with having the physician sign a 'release'. If you think about it, the determination of which unit is used for transfusion is under the license of the Medical Director of the Blood Bank. So, 'we' decide what is best to tranfuse, the ordering physician is made aware of any additional risks so that he/she can decide whether it is worth proceeding with the transfusion.

IF 'we' don't feel that the blood is 'safe' to transfuse (eg. that hemolysis case described in this string), then we don't have any units to offer. If the physician wants blood anyway, he/she has to sign for 'uncrossmatched blood' and assume all the risks.

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  • 2 weeks later...

The patient's MD should be explaining all the vagaries of these transfusions during the informed consent process. The release form provides the documentation that the MD is aware of the situation at hand. The quality people who think the patient should sign that form have no idea of what quality means . . . and it is unfortunate that more and more resources are being allocated to these folks instead of into patient care areas (like blood bank of course) . . . sorry, I had to vent that one.

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