Calling all ECHO users

[Jives]

Hi all, we are having a recurring antibody problem on our ECHO and i was wondering if anyone else is see this:

ECHO screen strongly pos: 3-4+

PEG screen neg-2+

LISS screen neg

cold screen 1-3+ only at 4 degrees

DAT neg

we have seen 6 of these in the last three weeks, i thought maybe it could be a strip problem but one of them had an ECHO panel run and it was 3-4+ also

the only thing we can find is a cold auto at 4 degrees, but i thought ECHO did not detect these!!

i am going to call immucor again, but they haven't been too helpful to this point:cries:

[AMcCord]

Have you tried running an auto control by crossmatching the patient's own cells with his/her plasma in these cases? I would still mull over the idea of some kind of autoantibody since PeG picks it up and LISS doesn't, especially if the auto is positive. Are these patient's who could have a mixed type cold/warm autoantibody? Any similarities between them in terms of diagnosis and medication.

Interesting - we've seen patients who react on Echo and with PeG, no specificity, and don't with LISS and gel. Some that react on Echo, but not with PeG and don't have a specificity with Echo. But none of them have had a positive cold screen as well. The cold antibody could be a red herring...by that, I mean that it just happens to be present in these patients, but is not related to the reactions you are seeing with Echo and PeG. We do see patients that we say have a solid phase reactive antibody of undetermined specificity that is non-reactive with (LISS, PeG, gel - pick the appropriate method). We had patients that did the same thing in gel. They often react 3-4+. HLA antibodies??? Antibodies to something in the reagents??? These sensitive methods may just be giving us reactions to things we don't care about.

[L106]

We have found that Warm Auto-Antibodies are characteristically enhanced on the Echo and weaker (or possibly nonreactive) with tube technique. (We use PeG with our tube technique; I can't offer any info for LISS or gel.)

However, it has been our experience that Cold Auto-Antibodies can go either way on the Echo. Many times the Cold Auto-Antibody will show up with Peg/tube technique, but be negative on the Echo. However, certain other patients with Cold Auto-Antibodies demonstrable with Peg/tube technique show up even stronger on the Echo.

Sorry I can't give an explanation! I'd love to hear one if anyone has one!

[bbbirder]

It does sound like some kind of auto.

We have seen some autos show up fairly strongly on the Echo, but not in tube or with gel. The (tube) DATs may or may not be positive on these patients.

We recently had a patient with a very clear anti-C and what turned out to to be an auto-anti-e on the Echo but was both the auto and the allo were very weak (almost not visible) in gel and all neg in tube.

Having different methods is helpful.

Linda Frederick

[Jives]

Have you tried running an auto control by crossmatching the patient's own cells with his/her plasma in these cases? I would still mull over the idea of some kind of autoantibody since PeG picks it up and LISS doesn't, especially if the auto is positive. Are these patient's who could have a mixed type cold/warm autoantibody? Any similarities between them in terms of diagnosis and medication.

Interesting - we've seen patients who react on Echo and with PeG, no specificity, and don't with LISS and gel. Some that react on Echo, but not with PeG and don't have a specificity with Echo. But none of them have had a positive cold screen as well. The cold antibody could be a red herring...by that, I mean that it just happens to be present in these patients, but is not related to the reactions you are seeing with Echo and PeG. We do see patients that we say have a solid phase reactive antibody of undetermined specificity that is non-reactive with (LISS, PeG, gel - pick the appropriate method). We had patients that did the same thing in gel. They often react 3-4+. HLA antibodies??? Antibodies to something in the reagents??? These sensitive methods may just be giving us reactions to things we don't care about.

dear AMcCord

i know this is a late response, but we are having more and more (3 in the last two days!!!) trouble with these and i was wondering if you might tell me how you are handling these.(what all do you do to work them up)...in particular how do you report them to the physician?!!?:confused: and do you tell them they (solid phase reactive antibodies) are clinically insignificant?!?!? do they ever call to say "What are these? " thanks, jane

[L106]

I'm not Ann, but I will answer.

If our Echo Antibody Screen is Positive, and our Peg/Tube Antibody Screen is Negative, and the Screens & Auto are 3+ or 4+ Pos when tested at 5C for 15 minutes, we report out a "Cold Auto-Antibody present".

We will then write a note on their record card that we keep in Blood Bank, saying something like: "Cold autoantibody detected on the Echo, but neg with Peg/Tubes. Recommend tube testing in the future." (And if we do Peg/Tube testing the next time and see no reaction, we report the Antibody Screen as "Neg".)

Donna

Edited February 24, 2010 by L106

[AMcCord]

If we get a positive antibody screen on Echo and an ID that is non-specific/indeterminate we run another screen with PeG/tube. If that screen is negative with a negative auto or negative tube DAT we report the antibody screen as Positive with 'solid phase reactive antibodyof undetermined specificity'. If we have a positive DAT on Echo or with tube with the scenario above, and all screen cells are positive on Echo, we would call it a warm auto. If a crossmatch is ordered in a case like this, we would do an IS and tube AHG/PeG crossmatch. If the IS and AHG/PeG crossmatches are compatible, we would release the blood for transfusion with the comment that the unit is compatible in AHG with PeG. If the IS crossmatch is incompatible, then we would look for rouleaux or cold reactive antibody to explain the IS results. If the problem is a cold (P1, M, N, etc) that is not clinically significant (and is AHG compatible) we would not screen for antigen negative units. (Please note that we do not do cardiac surgery here.) If the PeG screen is positive, then we are going to do more of a workup, such as an ID panel with PeG, a repeat screen with LISS, elution if indicated by patient history, etc. We may still end up calling it a warm auto or antibody of undetermined specificity, but we've worked it up more fully before we do that. If we are still not satisfied with what we are seeing, especially if the patient has a warm auto that we can't minimize with PeG or LISS, then we send it out to our reference lab.

We used gel for almost 9 years and we had similar looking antibody situations with that and that's where this approach came from. We have never had a physician question or even ask about the reports on these patients. If we feel that the antibody is significant (warm auto), the physician decides whether or not he/she wants to continue with the transfusion.

I've had discussions with the reference techs about these kinds of reactions and their feeling, based on experience and discussions with other reference labs, is that we are probably picking up autoantibodies that are more enhanced by solid phase than our tube methods, HLA antibodies, drug related antibodies (which we don't see if the patient doesn't have that drug in question in their system) or antibodies directed against preservatives or other chemicals in our test system. These types of antibodies are a pain in the posterior for us but probably not significant in terms of transfusing the patient, though I'm not going to report that. The patients we see with these problems are usually Onc, cardiology, and frequent flyers with multiple serious health issues. They've been multiply transfused, multiply drugged and their immune systems are not like yours or mine, so it's hardly surprising that they cause us problems.

Bottom line - if we're not comfortable with the what we see with repeat screens or IDs in tube, we send it out. But we don't have to do it too often.

Edited February 25, 2010 by AMcCord

[Jives]

If we get a positive antibody screen on Echo and an ID that is non-specific/indeterminate we run another screen with PeG/tube. If that screen is negative with a negative auto or negative tube DAT we report the antibody screen as Positive with 'solid phase reactive antibodyof undetermined specificity'. If we have a positive DAT on Echo or with tube with the scenario above, and all screen cells are positive on Echo, we would call it a warm auto. If a crossmatch is ordered in a case like this, we would do an IS and tube AHG/PeG crossmatch. If the IS and AHG/PeG crossmatches are compatible, we would release the blood for transfusion with the comment that the unit is compatible in AHG with PeG. If the IS crossmatch is incompatible, then we would look for rouleaux or cold reactive antibody to explain the IS results. If the problem is a cold (P1, M, N, etc) that is not clinically significant (and is AHG compatible) we would not screen for antigen negative units. (Please note that we do not do cardiac surgery here.) If the PeG screen is positive, then we are going to do more of a workup, such as an ID panel with PeG, a repeat screen with LISS, elution if indicated by patient history, etc. We may still end up calling it a warm auto or antibody of undetermined specificity, but we've worked it up more fully before we do that. If we are still not satisfied with what we are seeing, especially if the patient has a warm auto that we can't minimize with PeG or LISS, then we send it out to our reference lab.

We used gel for almost 9 years and we had similar looking antibody situations with that and that's where this approach came from. We have never had a physician question or even ask about the reports on these patients. If we feel that the antibody is significant (warm auto), the physician decides whether or not he/she wants to continue with the transfusion.

I've had discussions with the reference techs about these kinds of reactions and their feeling, based on experience and discussions with other reference labs, is that we are probably picking up autoantibodies that are more enhanced by solid phase than our tube methods, HLA antibodies, drug related antibodies (which we don't see if the patient doesn't have that drug in question in their system) or antibodies directed against preservatives or other chemicals in our test system. These types of antibodies are a pain in the posterior for us but probably not significant in terms of transfusing the patient, though I'm not going to report that. The patients we see with these problems are usually Onc, cardiology, and frequent flyers with multiple serious health issues. They've been multiply transfused, multiply drugged and their immune systems are not like yours or mine, so it's hardly surprising that they cause us problems.

Bottom line - if we're not comfortable with the what we see with repeat screens or IDs in tube, we send it out. But we don't have to do it too often.

Hey Ann......thanks so much for the answer....it will help when i get together with my medical director to talk about how to handle these!!!! i don't know if your interested but there was an article in

"Transfusion and Apheresis Science" August 2006 called "Comparative sensitivity of solid phase versus PEG enhancement assays for detection and identification of RBC antibodies" of all the positives they saw almost 35% were neg with PEG!! thanks again, jane:)

[dingalls2]

we have been seeing the positive screen, negative panel more just recently. Is there something about the last couple of lot #s that's different???

[AMcCord]

You're welcome, Jane. I'll see if I can find that article. One thing we weigh against all those funky results is the number of antibodies we detect with solid phase that are not detected by tube methods or are weak enough that they are difficult to ID or can't be ID'd with tube. It makes the aggravating ones a little more bearable.

[AMcCord]

we have been seeing the positive screen, negative panel more just recently. Is there something about the last couple of lot #s that's different???

I swear we see more of these kinds of nasties in the winter time. Maybe it's just me

[jim c]

We have a Galileo and have seen 6 or 7 in the last two weeks that look similar to these. We think it's the colds. As much as Immucor says they won't be detected, they are. I also agree that this happens more in the winter. March is almost here, hopefully soon it will all be gone.

[RR1]

Has anyone actually worked out how much extra this costs your lab to perform additional follow-up investigations of these non-spec results compared to the number of non-spec results obtained by a gel -card system?

[AMcCord]

We actually see slightly fewer non-specific problems with Echo than we were seeing with gel. And we are identifying antibdodies with Echo that we would not have been able to ID with gel or PeG (and not all of them are RhoGAM ;>). For us, that trade off makes it less of a burden.

[dal6164]

This is interesting we have just purchased an Echo and this is good to know. I was wondering if anyone could send me some info on how any of you guys did your corelation studies before going live. Did you just do the validation guide or run x number of samples? Any advice would be appreciated.

[L106]

This is interesting we have just purchased an Echo and this is good to know. I was wondering if anyone could send me some info on how any of you guys did your corelation studies before going live. Did you just do the validation guide or run x number of samples? Any advice would be appreciated.

dal6164 -

I'd be glad to email our validation plan to you. Send me a PM (Private Message) telling my your email address. (To send a PM, click on "Community" in upper left area of this screen, then select "Member List", then find my code L106.)

[sdarmor1]

Hi all, we are having a recurring antibody problem on our ECHO and i was wondering if anyone else is see this:

ECHO screen strongly pos: 3-4+

PEG screen neg-2+

LISS screen neg

cold screen 1-3+ only at 4 degrees

DAT neg

we have seen 6 of these in the last three weeks, i thought maybe it could be a strip problem but one of them had an ECHO panel run and it was 3-4+ also

the only thing we can find is a cold auto at 4 degrees, but i thought ECHO did not detect these!!

i am going to call immucor again, but they haven't been too helpful to this point:cries:

We had quite a few of these during the months of Jan and Feb. Quite a few of our patients are on ACE inhibitors, so I'm wondering if this may be playing a role in this situatiuon. We hadn't thought about the COLD angle, but will definately remember this next winter, if we see this again. Thought it might have been a lot# issue on the ECHO??? Didn't like the gel because of the rouleaux rxs, now don't know what to make of this solid phase issue???

[AMcCord]

Every methodology is going to have its own unique problems. You just have decide how far you are going to go with your workup to fit into your comfort zone for patient safety.

[fgrano]

We are a system of four hospitals which have been live with ECHO for about 6 months. Each of our facilities has experienced this type of activity at a rate in excess of what we would like. Typically these cases test negative with standard tube procedures. While we check things out thoroughly, typically we end up defaulting to tried and true methods and moving forward without difficulty. While it is unnerving to say the least, I feel this is inherent in Capture and that recent changes in the operating software will not alleviate the situation. One tends to feel you are backing away from a more sensitive method, but if that method fails to yield a clear result should it drive unnecessary testing and effort? In general such cases have not resulted in any specificity upon further admissions, and tend to be attempted on ECHO occasionally to see if there is any change – if not, being taken directly to the bench.

[Malcolm Needs ☆]

We are a system of four hospitals which have been live with ECHO for about 6 months. Each of our facilities has experienced this type of activity at a rate in excess of what we would like. Typically these cases test negative with standard tube procedures. While we check things out thoroughly, typically we end up defaulting to tried and true methods and moving forward without difficulty. While it is unnerving to say the least, I feel this is inherent in Capture and that recent changes in the operating software will not alleviate the situation. One tends to feel you are backing away from a more sensitive method, but if that method fails to yield a clear result should it drive unnecessary testing and effort? In general such cases have not resulted in any specificity upon further admissions, and tend to be attempted on ECHO occasionally to see if there is any change – if not, being taken directly to the bench.

Are you really backing away from a more sensitive method, or simply backing away from an over sensitive method???????

:confused::confused:

[fgrano]

Time will tell I suppose? I have mentioned this level of sporadic results to Immucor a number of times. I imagine / hope that if all users are experiencing same it will get back to them and foster aggressive measures to address it. At this point I still favor our choice of ECHO / Capture, but would like to see the company be more sensitive to such concerns. Impression of the operator in the field will affect marketability in the end.

[donde]

We just recently finished our training week on the Echo and are wondering if anyone out there has developed any procedures/policies to address equivocal reactions. ...do you always do more testing or sometimes decide its negative after visual review? ...how much retesting are you doing? My supertrainers understand this is a site defined determination, but we would welcome your thoughts.

:juggle:

[fgrano]

We just recently finished our training week on the Echo and are wondering if anyone out there has developed any procedures/policies to address equivocal reactions. ...do you always do more testing or sometimes decide its negative after visual review? ...how much retesting are you doing? My supertrainers understand this is a site defined determination, but we would welcome your thoughts.

:juggle:We do not have protocol expressly designed to address these situations. Typically we are running ECHO ID panel with an ECHO DAT. Having found there to be no clear answer, we are moving back to tube methods. Sometimes the ECHO DAT's are positive (more often with what appear to be pan-agglutinins), more often they are negative. We have been using the bench anti-globulin assays here as well to help come to a decision. Along with the total picture of solid phase and tube results the patient's transfusion history is given strong consideration. It has been our experience most of these cases do not reflect activity in tube - either in an ID panel or in the anti-globulin tests. While not every case is the same, in bulk we are proceding on basis of tube technology rather than allowing the ECHO to drive extra esoteric testing or use of a reference lab. We have taken this course primarily owing to the rate at which this is occurring vs the expense and effort to place entire faith in solid phase reactivity. Perhaps we are wrong, perhpas not - it remains my opiniononly more field experience with this analyzer will tell the true story.

[sdarmor1]

:cries:We had been seeing an issue with lot #R084 of the ready screen strips...cell #2 has been positive in Females under 40. When the Ready ID was run there was no specific pattern seen, only 2 cells would be positive and these weren't an identifiable antibody. We had 9 patients with this problem in our 16 boxes of this lot #. We are now using lot#R094 and seem to be having a problem with screening cell #2, again. This time both the Ready ID and the Extend I are completely negative??? Has anyone else had issues with these lot #'s??? Could this be Bg activity??? Not well versed on Bg and HTLA antibodies, would appreciate input.

[fgrano]

Your description of patient behavior on ECHO here is strikingly similar to a number of cases we have had, though I could not pin it to an age / sex bias. Indeed, we have surmised the possibility of particular Lot’s though. To tell you the truth, in the end I simply will not put the effort in to pursuit of this – be it Bg, or whatever. My opinion remains that Immucor has a small problem to deal with along the lines of non-specific results, and field experience with this machine will drive resolution. I’ve quite frankly begun to wonder if one could put five male patients with no history of transfusion on ECHO, run panels on each, and come away without some kind of non-specific hit on at least one of them in the 2+ to 3+ range!