Incompatible Warm Auto: Dr's Sign?

[Mehaffey]

I work in a hospital that does differential adsorptions for warm autos. We identify and/or rule out alloantibodies and crossmatch using the adsorbed plasma. My question is: even though the crossmatches may "appear" compatible in vitro, they are not really compatible in vivo. All we have done is to make sure there are no alloantibodies present. The patient's autoantibody will react to the transfused cells, causing further hemolysis. The units go out on these patients as compatible, and the doctors do not have to sign for them, even though they are not truly compatible. I am wondering what the policy is in other hospitals regarding these adorbed-plasma-crossmatched units being called "compatible" vs. "incompatible" and the doctors having to sign for them. I'd appreciate hearing everyone's idea on this. Thanks.

[Malcolm Needs ☆]

Being a Reference Laboratory, we also perform differential alloadsorptions on such patients (or auto-adsorptions if the patient has not been transfused within the previous 3 months [rare] and if there is sufficient autologous red cells [almost never]).

As you may have seen from my posts on threads asking similar (but not identical) questions, I have no problem issuing blood that reacts in vitro with the auto-antibody in the patient's raw palsma, unless the haemolysis is fulimating.

When issuing this blood we do not need a doctor's signature, but we would not issue it either as compatible, or as incompatible, but would issue it as "suitable for".

In addition, we print a phrase on the bottom of the cross-match form that goes out to the hospitals as follows:

"Please note that when suitable blood, rather than compatible blood is provided, observation of the patient during transfusion is of paramount importance."

I am almost happy with this, except that the phrase itself seems to imply that observation of the patient during transfusion is not of paramount importance for any other transfusion, which is, of course, complete nonsense!

:)

[Marilyn Plett]

There was an excellent article in Transfusion (early 2008?) that discussed this issue. If I remember correctly, the gist was that the attending physician unlikely to understand the issues, and it was unreasonable for him/her to sign for something they didn't understand. The hospital's blood bank Medical Director should make the decision about "compatibility," and discuss it with the physician.

[BSIPHERD]

When a unit is incompatible with neat plasma and no reaction is seen with auto or with differentially adsorbed plasma, we review it with a pathologist. If the pathologist okays transfusion, we call the crossmatch INCOMPATIBLE-OK'ed. We also add a comment to the order that says where nnnn is the pathologist's name.

UNITS ARE INCOMPATIBLE. TRANSFUSION OF INCOMPATIBLE UNITS REQUIRES DIRECT CONSULTATION WITH A PATHOLOGIST. TRANSFUSION OK'ED BY DR. nnnnn.

If differentially adsorbed plasma showed no alloantibodies, we also add a comment

No underlying alloantibodies were detected when differentially adsorbed plasma was used. However, antibodies to high incidence antigens cannot be ruled out.

[Brenda K Hutson]

We do not use adsorbed plasma to XM with. That is only creating a serological situation in which the XM is compatible, just because the Physician likes to see that; we all know that it is still incompatible by a different method (although I suppose you could argue that it would catch a Low Incidence if there). We report it out as Least Incompatible, but I do have the staff call the RN and MD to let them know what they will see on the paperwork, and to try and explain it somewhat. I have not encountered problems at this Hospital with Physicians refusing to give the blood because it states that (not even with them arguing about it; perhaps they were educated previous to my coming here). One place I did previously work, would require the MD to sign to receive Least Incompatible blood (again, not crossmatching with adsorbed plasma).

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

We do not use adsorbed plasma to XM with. That is only creating a serological situation in which the XM is compatible, just because the Physician likes to see that; we all know that it is still incompatible by a different method (although I suppose you could argue that it would catch a Low Incidence if there). We report it out as Least Incompatible, but I do have the staff call the RN and MD to let them know what they will see on the paperwork, and to try and explain it somewhat. I have not encountered problems at this Hospital with Physicians refusing to give the blood because it states that (not even with them arguing about it; perhaps they were educated previous to my coming here). One place I did previously work, would require the MD to sign to receive Least Incompatible blood (again, not crossmatching with adsorbed plasma).

Brenda Hutson, CLS(ASCP)SBB

In principle, I do agree with you Brenda, but when we detect an underlying atypical alloantibody post-adsorption (say an anti-Fyb for arguement's sake), we do like to cross-match, just to make sure that we are not giving Fy(b+) blood (albeit, the cross-match could easily miss an Fy(a+b+) unit if the anti-Fyb is very weak).

[knail]

As a Reference Lab, we perform alloadsorbtions quite frequently. We only perform AHG crossmatches on unadsorbed plasma, rather than alloadsorbed plasma, and select the "least incompatible" units. Our reports only state "least incompatible" with all units distributed as crossmatched on patients with autoantibodies. This was a decision OUR medical director made. We don't want to sugar coat the issue of compatibility in these patients because of the in vivo response to the units. Recommendations are to avoid transfusions in these patients, thus it makes the clinician think twice before transfusing. I think we are providing misleading information if we report the units as compatible. Our local hospitals are doing the same procedure and make the clinician sign a release form for the units. They may not like it, but the ultimate decision to transfuse these units is in their hands. If problems with the clinician arise, refer them to the medical director.:eyepoppin

[Brenda K Hutson]

In principle, I do agree with you Brenda, but when we detect an underlying atypical alloantibody post-adsorption (say an anti-Fyb for arguement's sake), we do like to cross-match, just to make sure that we are not giving Fy(b+) blood (albeit, the cross-match could easily miss an Fy(a+b+) unit if the anti-Fyb is very weak).

I can see your point, though I guess I was just focused on the warm autoantibody, not an underlying alloantibody. I guess that kind of goes with the same reasons we perform coombs crossmatches on patients with clinically significant alloantibodies; both to catch a unit that had erroneous antigen typing results, and to catch a possible Low (given that we are dealing with an "antibody producer").

Anyway, all of that being said, none of the places I have worked have routinely crossmatched with adsorbed serum. The only exception would be when I was a supervisor at a Red Cross Reference Lab; on rare occassion, we would get a Hospital that asked us to perform crossmatches with adsorbed plasma. We did not routinely crossmatch for our clients, only perform antibody ID and Antigen Screening.

Brenda Hutson, CLS(ASCP)SBB

[carolyn swickard]

We crossmatch with the unabsorbed plasma and report the units out as "Least Incompatible" too. We have a simple chart form called the "Blood Transfusion Consultation Record" though. We record the problem on the top of the form, record which/when we refer it to a pathologist and the pathologist calls and records the consultation with the attending physician (who/date/time/what was discussed

/recommended) and then the pathologist signs the form and we send the original to the pt's chart. We keep a copy in the Bank but have never had to use them. CAP and FDA inspectors have seen the forms, but have never said one way or the other whether they like them or not. The Dr does not have to come and sign the form, but their name is on the form on the chart.

[Malcolm Needs ☆]

I can see your point, though I guess I was just focused on the warm autoantibody, not an underlying alloantibody. I guess that kind of goes with the same reasons we perform coombs crossmatches on patients with clinically significant alloantibodies; both to catch a unit that had erroneous antigen typing results, and to catch a possible Low (given that we are dealing with an "antibody producer").

Anyway, all of that being said, none of the places I have worked have routinely crossmatched with adsorbed serum. The only exception would be when I was a supervisor at a Red Cross Reference Lab; on rare occassion, we would get a Hospital that asked us to perform crossmatches with adsorbed plasma. We did not routinely crossmatch for our clients, only perform antibody ID and Antigen Screening.

Brenda Hutson, CLS(ASCP)SBB

Our National SOP actually states that we should cross-match with the raw plasma and the adsorbed plasma, if there is sufficient raw plasma available.

On average, we deal with about 4 or 5 DAT positive samples a day, most with a panagglutinin giving a 4+ or 5+ reaction across the board. I've never quite seen the point of cross-matching against the raw plasma in such circumstances, knowing before I start that the units will be 4+ or 5+ incompatible. It's a waste of time (1+ or 2+ panagglutinins maybe, but not when they are that strong). You would be amazed just how many times I have insufficient raw plasma left to perform these useless cross-matches!

The 50 odd hospitals that we deal with as their Reference Laboratory (from very large London Teaching Hospitals to small Private Hospitals) are a varying lot too.

SOme are quite happy to perform an immediate spin cross-match if we detect no atypical alloantibodies following differential adsorption, some will do this if the auto-antibody is 1+ to 2+, but will want us to cross-match if the auto-antibody is strong, or if we identify atypical alloantibodies following differential alloadsorption, whilst others (some quite reasonably sized District General Hospitals) want us to cross-match for them even when the autoantibody results in 2 cells kissing each other in the IAT. This last cohort really annoy us!

:mad::mad:

[tbostock]

I don't use the term "least incompatible". I believe it gives the physician a false sense of security that one unit might cause less of a reaction in a patient just because it was weaker in vitro. There have been studies that have shown that the strength of reaction in the test tube does not correlate at all with what would happen in the patient.

We call them just plain "incompatible" and have the physician sign. If the attending hesitates signing, we recommend a hematology consult, which the attending usually goes with.

Here's a good discussion about the "least incompatible" term: http://www.cbbsweb.org/enf/2005/incompat_term.pdf

[Brenda K Hutson]

I don't use the term "least incompatible". I believe it gives the physician a false sense of security that one unit might cause less of a reaction in a patient just because it was weaker in vitro. There have been studies that have shown that the strength of reaction in the test tube does not correlate at all with what would happen in the patient.

We call them just plain "incompatible" and have the physician sign. If the attending hesitates signing, we recommend a hematology consult, which the attending usually goes with.

Here's a good discussion about the "least incompatible" term: http://www.cbbsweb.org/enf/2005/incompat_term.pdf

Well, and in all honesty, most of the Warm Autos show the same strength so it is nothing more than a terminology. I think that is a common term that is used though. I guess in my mind, it is ALL just about teminology; creating a report that makes the Physicians feel more comfortable with transfusing the blood. It still reacts where it reacts; that is just the way it is.

Also, I guess I don't think of the false security of being so much of an issue for the following reasons:

1. Most Warm Autoantibodies are not hemolytic anyway

2. For the Warm Autoantibodies that are hemolytic, we recommend steroids instead of transfusion, and should they

choose to transfuse anyway, we do tell the Nurse to monitor that patient more frequently than the general

transfused patient population.

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

There ws an editorial, written by Lawrie Petz, a few years ago in Transfusion that may be of interest to people. It is:

Petz LD. "Least incompatible" units for transfusion in autoimmune hemolytic anemia: should we eliminate this meaningless term? A commentary for clinicians and transfusion medicine professionals. Transfusion 2003; 43: 1503-1507.

The final paragraph should be of particular interest.

:)

[tbostock]

Excellent editorial; thanks Malcolm! He explains it in a nutshell.

[Malcolm Needs ☆]

No problem (after all, he wrote it, not me)!!!!!!!!!!!

:D

Edited August 6, 2009 by Malcolm Needs

[Eagle Eye]

We do not crossmatch with adsorbed plasma but crossmatch with raw plasma...and issue as incompatible but we require blood bank director's approval and patient's physician's signature on our form.

[Brenda K Hutson]

There ws an editorial, written by Lawrie Petz, a few years ago in Transfusion that may be of interest to people. It is:

Petz LD. "Least incompatible" units for transfusion in autoimmune hemolytic anemia: should we eliminate this meaningless term? A commentary for clinicians and transfusion medicine professionals. Transfusion 2003; 43: 1503-1507.

The final paragraph should be of particular interest.

:)

Is there a way to access Transfuson online? I have never done it and don't want to search the Lab for that specific issue.

Thanks,

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Is there a way to access Transfuson online? I have never done it and don't want to search the Lab for that specific issue.

Thanks,

Brenda Hutson, CLS(ASCP)SBB

Hi Brenda,

If there is, then I'm afraid I don't know it.

You could try going onto the Transfusion website, but I suspect you would have to pay for any downloads.

Occasionally, very occasionally, you can Google and get a paper up.

Sorry I can't be more help.

The only other thing I can suggest is that you send me an email on malcolm.needs@nbs.nhs.uk with your work address, and then I can photocopy my copy and send it to you.

Sorry, not a lot of help I know.

:redface::redface:

Good news! I've just Googles Transfusion AABB and managed to get the article up that way, so you can get via their site!

:):):)

Edited August 6, 2009 by Malcolm Needs

[Marilyn Plett]

If you are an AABB member, you can access Transfusion online. I did it once but have since forgotten how. Maybe you can e-mail AABB for directions.

[Malcolm Needs ☆]

Tonight (its 21.30 over here) I found the article on the computer by going into:

Google

Put in "Transfusion AABB"

Go to "Transfusion - Journal Information"

Once in, over on the right hand side is a bit marked "view sample issue"

Go to 2003 - Volume 43 and expand it.

Go to Issue 11 (November 2003).

Go to the editorial and you can download a PDF of the article.

AND, I KNOW YOU WON'T BELIEVE THIS, BUT IT WAS FREE!!!!!!!!!!!!

:D:D

[Brenda K Hutson]

Tonight (its 21.30 over here) I found the article on the computer by going into:

Google

Put in "Transfusion AABB"

Go to "Transfusion - Journal Information"

Once in, over on the right hand side is a bit marked "view sample issue"

Go to 2003 - Volume 43 and expand it.

Go to Issue 11 (November 2003).

Go to the editorial and you can download a PDF of the article.

AND, I KNOW YOU WON'T BELIEVE THIS, BUT IT WAS FREE!!!!!!!!!!!!

:D:D

Wow, thank you so much for taking the time to do that! No doubt I will agree with whatever his stance was. Even though places I have worked have historically referred to it as "Least Incompatible," my current Hospital only has 2 selections at present: Compatible and Incompatible. I do put a comment in a patient's file if they have a Warm Auto, stating to use LISS. But again, it is all just an issue of trying to get a result that the MD will be happy with; it does not change anything about the reactions we get by various methods. And again, if we are giving Incompatible, we will discuss this with the Nurse so they know what to expect.

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Wow, thank you so much for taking the time to do that! No doubt I will agree with whatever his stance was. Even though places I have worked have historically referred to it as "Least Incompatible," my current Hospital only has 2 selections at present: Compatible and Incompatible. I do put a comment in a patient's file if they have a Warm Auto, stating to use LISS. But again, it is all just an issue of trying to get a result that the MD will be happy with; it does not change anything about the reactions we get by various methods. And again, if we are giving Incompatible, we will discuss this with the Nurse so they know what to expect.

Brenda Hutson, CLS(ASCP)SBB

It's a pleasure.

[Liz]

Where has the thank you button gone ;-(

Thank you Malcolm!!!

Liz