Massive transfusion with an antibody

[John C. Staley]

The problem is, those folks in the surgical suites and emergency rooms feel that screaming at the top of their lungs that they need everything RIGHT NOW is good communication. More often than not, when searching for info on a trauma paitient I've been told: "I don't have time to answer any questions, don't you care that the patient is dying?" or some variation of that sentiment.

What is important to us is of no importance to those folks and if anyone were to figure out how to make it important to them I would put your name on the ballot for a Noble Peace Prize. I imagine that would qualify.

[jcdayaz]

The problem is, those folks in the surgical suites and emergency rooms feel that screaming at the top of their lungs that they need everything RIGHT NOW is good communication. More often than not, when searching for info on a trauma paitient I've been told: "I don't have time to answer any questions, don't you care that the patient is dying?" or some variation of that sentiment.

What is important to us is of no importance to those folks and if anyone were to figure out how to make it important to them I would put your name on the ballot for a Noble Peace Prize. I imagine that would qualify.

I agree completely!! I will second the nomination for the Nobel Peace Prize!!

Did you see a post I made awhile ago about being SCREAMED at by a transplant surgeon to sh*t the platelet pheresis out of my a*s even though there were no more in the whole city??!!

I especially appreciate (not) the apparent lack of communication between people during one of these crisis situations. Multiple different people calling for the same product, etc. I have resorted on a few occasions to saying "I can get that product ready for you much faster if you guys will stop calling me every minute". I have also told OR/ER people that I want a designated contact person...ie..the same person calling each time---seems to help the confusion factor...

Really, I'm surprised I haven't been terminated!!

[Malcolm Needs ☆]

I agree with both the last two posts (well, not the termination bit, but the rest).

[adiescast]

I think part of the key is to help them to see us as part of their team. This can eliminate the "us versus them" concept that everyone seems to work under. I have had some success in talking with the trauma team outside of the situation and explaining things like:

1) Telling the blood bank to send everything they have is not an order for blood, particularly when the blood bank doesn't even know you have a patient who is bleeding.

2) An order for blood on the chart in the nursing area does not communicate the need for blood to the blood bank. (hopefully electronic ordering will alleviate tis problem....if we ever get it!)

3) People do not respond well to screaming and cursing, so if you need a quick response, just tell them what you need and that you need it urgently.

I have had less success with getting them to stop blaming things on the lab when things don't go well. My favorite example of this is personal. I accompanied my mother to the ER when my mentally retarded uncle had a seizure and a bad fall. We stood by his bed all night (no one offered us a chair). At the end of the night, a nurse told us they could release my uncle, but they were waiting for the lab results. After she left, I asked my mother if they had drawn samples that I missed. She said they had not. I said that it would be difficult to get lab results without a sample.

[Malcolm Needs ☆]

I think part of the key is to help them to see us as part of their team. This can eliminate the "us versus them" concept that everyone seems to work under. I have had some success in talking with the trauma team outside of the situation and explaining things like:

1) Telling the blood bank to send everything they have is not an order for blood, particularly when the blood bank doesn't even know you have a patient who is bleeding.

2) An order for blood on the chart in the nursing area does not communicate the need for blood to the blood bank. (hopefully electronic ordering will alleviate tis problem....if we ever get it!)

3) People do not respond well to screaming and cursing, so if you need a quick response, just tell them what you need and that you need it urgently.

I have had less success with getting them to stop blaming things on the lab when things don't go well. My favorite example of this is personal. I accompanied my mother to the ER when my mentally retarded uncle had a seizure and a bad fall. We stood by his bed all night (no one offered us a chair). At the end of the night, a nurse told us they could release my uncle, but they were waiting for the lab results. After she left, I asked my mother if they had drawn samples that I missed. She said they had not. I said that it would be difficult to get lab results without a sample.

I agree entirely (especially, tongue in cheek, with the last bit)!.

:D:D:D:D

[L106]

I agree with both of those posts, too. (And Mabel's also.)

The multiple phone calls can really affect our efficiency. Many a time I have responded to the third (or fifth, or whatever) by saying "I understand you need the blood STAT, but I can't bring it to you while I'm standing here talking to you on the phone!" (jcdayaz's suggestion of requesting one designated contact person is a great idea.)

[Malcolm Needs ☆]

Yes, back some time ago, when the IRA bombed Harrods, I was working at Westminster Hospital (sadly, now closed). As you can imagine, it was a bit chaotic.

We had a wonderful Senior Registrar in Haematology/Blood Bank by the name of Rollo Lewis, who took it upon himself to act as our "runner" and to also act as a conduit between Accident and Emergency and us in Blood Bank so that we were well aware of what was going on, how many victims we were dealing with, how many were in need of blood as an emergency, how many needed blood urgently and how many could wait. He also told us how the various victims were doing (e.g. if they moved from one category to another).

I was the most senior person in the Lab that Saturday (a very basic grade technician) and I have never forgotten just how useful to me/us was the role adopted by Rollo.

He made a huge difference, and I am certain that this (good communication) is the key in such situations.

:):)

[KarenJ]

I had reached my limit with the phone one night. I told surgery after the 5th call, that because of all the interuptions I was going to have to start over and it would be another 45 minutes. After a gasp on the other end, the phone didn't ring again, and within 10 minutes I had the blood delivered to the OR frig. My supervisor was standing behind me and backed me up.

[Malcolm Needs ☆]

So he/she should have done.

Well done!!!!!!!!!!!

:D:D:D:D:D

[L106]

Excellent, KarenJ!! Good to have such a supportive supervisor. (Would have been even better yet if she took over answering the phone!)

[ANORRIS]

Any procedures to share on giving non antigen typed blood in a crisis?

[tbostock]

Give non antigen typed blood while the patient is massively bleeding. Identify the antibody and start screening units. Give antigen negative units when the patient's bleeding is under control.

[LaraT23]

You all are a total riot ,really!@

Firstly, our procedure states that once a person is classified as "massively transfused" ( 18-21 units in a 24 hour period) we can go to electronic crossmatch and use non-antigen typed units until the patient's hemoglobin/pressure raises to normal levels and or no units have been issued for 8 hours. Then we go back to antigen typed.

As far as phone calls, I have had four today about one patient. The first was a nurse who wanted to inform me that the testing on Mrs. so and so was only a type and cross. Okay? so?

Then another, oh those are on hold.. Okay so the refrigerator will "hold" them until you want them. Then two more to say, oh, uh We have an order to transfuse two units. Great, you can transfuse them as soon as you come and get them out of the refrigerator that is still holding them.

[Mabel Adams]

We don't have a procedure for massives with antibodies--partly because every case is so different. In addition to all else in this thread, I would try to respect Kidd system antibodies a bit more than the other specificities since they are more likley to fix complement and therefore cause intravascular hemolysis and all its sequelae. Some experts suggest trying to give the first few units antigen negative until the antibody is washed out, then switch to untested in the middle and top off with negative--save the best wine for last. This probably works better for planned massive transfusions like liver transplants.

We recently had an emergency with a previous anti-M (reacting with only homozygous and some hetero cells) and a historic anti-f that was not detectable. They were able to hold off transfusing until we could find some c neg units but we only had one that was M neg. After giving that unit, the other 3 c neg units were M pos but one was crossmatch compatible so they gave it while they waited for the state patrol to arrive from the blood center 3 hrs away with more units neg for both. She ended up getting a couple of those. A few days later, we had to repeat her antibody screen and her anti-M had gone from 1+ to 4+ but there was no evidence of increased bili or kidney issues. Her DAT was not positive either. I suspect that we had to transfuse her the second time partly because she probably destroyed the M pos unit, but slowly so that she had no signs or symptoms.

We are discussing this case at a dept meeting this week because I think that is the best way to have people think through all the issues of the case--including planning ahead for 6 hours from now and understanding how to transfuse someone with anti-f. It is too hard to write rules but the experience of having thought through the issues can help in future cases. It sort of ramps up the adrenalin too so it makes it easier to remember the discussion.

[Malcolm Needs ☆]

Hi Mabel,

Could you not just give R1R1 or R2R2 (but NOT R1R2, as these could be Rzr) for anti-f? This is what we do.

:confused:

[jcdayaz]

Any procedures to share on giving non antigen typed blood in a crisis?

If the "crisis" situation you are referring to is a trauma/massive bleed I do know from experience the blood is often times coming out as fast as it is going in. In most cases (not all, certainly) the blood is not present in the recipient's body long enough to stimulate a reaction.

No specific procedure in my current facility. Anything that deviates from protocol has to be cleared through the Blood Bank Medical Director (Pathologist) and have an "Emergency Release" form signed by the patient's physician

In a crisis situation obviously there is no time for the treating physician to sign a form. There is a line on our Emergency Release form that the nurse picking up the products can sign on behalf of the physician. Then after the crisis is over we get the treating physician to sign it. They always do.

[Mabel Adams]

Units neg for c are R1R1 units, right? We didn't try testing for e (R2R2) since the odds were pretty slim among our stock of some 45 O pos units that we would find even one. We don't have the luxury of looking up donors' historic phenotypes like blood centers do.

You are right about not looking for apparent R1R2 units (like the patient is) because there are some f positive genotypes possible in that CcDEe phenotype like you mentioned (Rzr). I assure you, I have been studying up on it lately, although I am sure I have more to learn.

[Malcolm Needs ☆]

Units neg for c are R1R1 units, right? We didn't try testing for e (R2R2) since the odds were pretty slim among our stock of some 45 O pos units that we would find even one. We don't have the luxury of looking up donors' historic phenotypes like blood centers do.

You are right about not looking for apparent R1R2 units (like the patient is) because there are some f positive genotypes possible in that CcDEe phenotype like you mentioned (Rzr). I assure you, I have been studying up on it lately, although I am sure I have more to learn.

Ah, fair point about the number of R2R2 units you would have available.

:D:D:D:D

[jcdayaz]

Malcolm,

We have a patient right now that we & our reference blood center are furiously trying to find units for. The patient has anti-Yta(proven to be clinically significant by MMA testing), E, c, K. The surgeon wants 2 units infused before surgery (total amputation planned) and 2 on hold during surgery. We were able to locate 1 frozen unit and transfused it this morning. Unfortunately, finding 3 MORE units is almost impossible. Our latest thinking is to transfuse (if totally necessary) with E,c,K negative blood and take our chances with the Yta. In our research clinically significant Yta causes "mild to moderate" reactions. Do you have any experience with clinically significant Yta's and the reaction it might cause?

Thanks in advance for your input. This is a nightmare!

[Steven Jeff]

Hi jcdayaz

I am afraid I don't know the answer to your questions. I was wondering why you are transfusing pre-op, is the patient anaemic? 4 units seems a lot to request for an amputation

Regards

Steve

:)

[Malcolm Needs ☆]

Malcolm,

We have a patient right now that we & our reference blood center are furiously trying to find units for. The patient has anti-Yta(proven to be clinically significant by MMA testing), E, c, K. The surgeon wants 2 units infused before surgery (total amputation planned) and 2 on hold during surgery. We were able to locate 1 frozen unit and transfused it this morning. Unfortunately, finding 3 MORE units is almost impossible. Our latest thinking is to transfuse (if totally necessary) with E,c,K negative blood and take our chances with the Yta. In our research clinically significant Yta causes "mild to moderate" reactions. Do you have any experience with clinically significant Yta's and the reaction it might cause?

Thanks in advance for your input. This is a nightmare!

Hi there,

We VERY rarely bother with Yt(a-) typed blood, unless the anti-Yta is seriously strong.

This is in line with the advice given in Daniels G, Poole J, De Silva M, Callaghan T, MacLennan S, Smith N. The clinical significance of blood group antibodies. Transfusion Medicine 2002; 12: 287-296.

"Anti-Yta Serologically least incompatible red cells, but antigen negative for strong examples of the antibody."

We have never come across even a mild haemolytic transfusion reaction following this advice.

I hope that helps!

Good luck!

Malcolm

:eek::D:D

[Likewine99]

I had a trauma surgeon tell me one time that he knew the BB would only send them what we knew was the best blood for the pt.

He said that a massively bleeding pt had so much going on that an antibody was the least of their problems.

There's also the fact that when a pt is bleeding out the blood is passing through them so fast that the antibody is diluted and their immune system wouldn't have time to react to the antigen anyway.

You do the best you can under the circumstances and keep your fingers crossed that there won't be more antibody problems down the road.

[jcdayaz]

Hi jcdayaz

I am afraid I don't know the answer to your questions. I was wondering why you are transfusing pre-op, is the patient anaemic? 4 units seems a lot to request for an amputation

Regards

Steve

:)

Yes, pre-op transfusion needed to get the patient stabilized (one of which we did yesterday morning) and 2 for surgery. This patient is a "special case" in that she has used multiple units over multiple years. I don't know the etiology of her anemia, but I do know the surgeon has done only partial amputations (I don't know what that means), but now is doing a full amputation. Or, needs to do one and will only schedule surgery when/if we find compatible blood.

[Malcolm Needs ☆]

Yes, pre-op transfusion needed to get the patient stabilized (one of which we did yesterday morning) and 2 for surgery. This patient is a "special case" in that she has used multiple units over multiple years. I don't know the etiology of her anemia, but I do know the surgeon has done only partial amputations (I don't know what that means), but now is doing a full amputation. Or, needs to do one and will only schedule surgery when/if we find compatible blood.

I don't know what it means either, but it conjures up the horrible thought of the limb being left dangling by a piece of flesh.

Yeuk!

:eek::eek:

[jcdayaz]

Hi there,

We VERY rarely bother with Yt(a-) typed blood, unless the anti-Yta is seriously strong.

Good luck!

Malcolm

:eek::D:D

What do you consider "seriously strong"? Do you foreign Techs:D have the same grading system we do here? As in 1+, 2+, 3+, 4+? If you do, what number is "seriously strong"?