Doing Rule Outs

[L106]

At the time that the patient was demonstrating anti-M and you couldn't rule out Anti-E, it would be prudent (ie: recommended) to make sure the donor units for the patient were E neg.

However, if you had no good reason to suspect that Anti-E was there, then the antibody screening is negative the next time, I would not type future donor units for the E antigen.

[generalist]

sorry maybe i was unclear , we did send it to arc they said it was a cold m (only that was it) 1mth later pt came back, i guess at this time the tech figures it would be easier to calll for m- and E- units rather than pkg pt up and sending to arc.i know that if you cant rule it out you would give antigen neg unitsat that time but next time is suppose to be a new time right?! i guess my main questions is does any else have this policy about once unable to rule it out , it goes in the pts file for life, i guess to me it feels like we are actually giving them a history of the antibody . i feel this is not a good policy (not to mention time and $) and was wondering if there was any reference i could pull to prove this ?

[generalist]

No we do not result an antibody in a permanant history just because it cannot be ruled out. Only firmly identified antibodies will be put there. Any that "cannot be ruled out" are dealt with for that visit only. The next time the patient comes in is a new look at those.

thanks laraT23, do you have a policy in place that states that or is it just something that everyone knows , as i thought i knew, hahaha

[L106]

I think I understand what you are trying to explain, generalist, and I agree with your logic. Let me propose two situations, and let me know if this supports your point, OK?

Situation #1:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q (ie: doesn't matter what we name it) (Donor units for him should be c neg and Q neg.)

April: Pt demonstrates Anti-c, but you have a new lot # of panel so you happen to be able to rule out Anti-Q. (So you only have to make sure donor units for him are c neg, right?)

May: Pt's antibody screen is negative. (So you only have to make sure donor units for him are c neg.)

Situation #2:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q. (Donor units for him should be c neg and Q neg.)

You don't see this pt in April.

May: Pt's antibody screen is negative. (My opinion is that you only have to make sure donor units for him are c neg.)

[generalist]

I think I understand what you are trying to explain, generalist, and I agree with your logic. Let me propose two situations, and let me know if this supports your point, OK?

Situation #1:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q (ie: doesn't matter what we name it) (Donor units for him should be c neg and Q neg.)

April: Pt demonstrates Anti-c, but you have a new lot # of panel so you happen to be able to rule out Anti-Q. (So you only have to make sure donor units for him are c neg, right?)

May: Pt's antibody screen is negative. (So you only have to make sure donor units for him are c neg.)

Situation #2:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q. (Donor units for him should be c neg and Q neg.)

You don't see this pt in April.

May: Pt's antibody screen is negative. (My opinion is that you only have to make sure donor units for him are c neg.)

YesYes Yes,

[generalist]

now i am trying to convince the techs i work with not to make this "unable to rule out" a give neg units for life.policy, any thoughts . we are a very small lab and all generalist's very conservative when it comes to bloodbank- like to "see" in black and white ( once it is written so shall it be!)

[Malcolm Needs ☆]

I think I understand what you are trying to explain, generalist, and I agree with your logic. Let me propose two situations, and let me know if this supports your point, OK?

Situation #1:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q (ie: doesn't matter what we name it) (Donor units for him should be c neg and Q neg.)

April: Pt demonstrates Anti-c, but you have a new lot # of panel so you happen to be able to rule out Anti-Q. (So you only have to make sure donor units for him are c neg, right?)

May: Pt's antibody screen is negative. (So you only have to make sure donor units for him are c neg.)

Situation #2:

March: Pt demonstrates Anti-c, but you cannot rule out Anti-Q. (Donor units for him should be c neg and Q neg.)

You don't see this pt in April.

May: Pt's antibody screen is negative. (My opinion is that you only have to make sure donor units for him are c neg.)

Yep! Now that I've finally got my head in gear, I totally and utterly agree with you Donna - mind you, I wish you hadn't chosen "anti-c" as one of your ficticious antibodies - that nearly got me confused all over again (an easy thing to do)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:D:D:D:D

[generalist]

does anyone have in place a policy that is for or against this?or a reference in AABB ???

[Deny Morlino]

Generalist,

Here is the AABB 26th edition standards section you are looking for:

5.14.3 When clinically significant red cell antibodies are detected or the recipient

has a history of such antibodies, Whole Blood or Red Blood Cell

components shall be prepared for transfusion that do not contain the

corresponding antigen and are serologically crossmatch-compatible.

Here is the section from the 16th ed Technical manual I think you need:

Whenever possible, RBC units selected for transfusion to a patient with potentially clini- cally significant antibodies should be tested and found negative for the corresponding antigen(s). Even if the antibody is no longer detectable, all subsequent RBC transfusions to that patient should lack the antigen in order to prevent a secondary immune response. The transfusion service must main- tain records of all patients in whom clinically significant antibodies have been previously identified, and an AHG- crossmatch proce- dure is required if the serum contains—or has previously contained—a clinically significant antibody.

Hope this helps.

[Malcolm Needs ☆]

Deny,

Do they define ANYWHERE what they consider to be clinically significant?

In 35 odd years in the business, I have only ever seen one clinically significant anti-A1, for example.

:confused::confused:

[Deny Morlino]

Let me look further. Stand by.

[Deny Morlino]

Here is what the technical manual has to say:

Whenever possible, RBC units selected for transfusion to a patient with potentially clini- cally significant antibodies should be tested and found negative for the corresponding antigen(s). Even if the antibody is no longer detectable, all subsequent RBC transfusions to that patient should lack the antigen in order to prevent a secondary immune response. The transfusion service must main- tain records of all patients in whom clinically significant antibodies have been previously identified, and an AHG- crossmatch proce- dure is required if the serum contains—or has previously contained—a clinically significant antibody.

and

A clinically significant red cell antibody is defined as an antibody that is frequently associated with hemolytic disease of the fetus and newborn (HDFN), with hemolytic transfusion reac- tions, or with a notable decrease in the sur- vival of transfused red cells. The degree of clinical significance varies among antibodies with the same specificity; some cause destruc- tion of incompatible red cells within hours or even minutes, whereas others cause a decrease in the red cell survival by only a few days, and still others cause no discernible shortened red cell survival. Some antibodies are known to cause HDFN, whereas others may cause a positive direct antiglobulin test (DAT) in the fetus without clinical evidence of HDFN.

After an antibody has been identified, it is important to determine its clinical signifi- cance. Antibodies that react at 37 C, by IAT, or both, are potentially clinically significant. Antibodies that react at room temperature and below are usually not clinically signifi- cant; however, there are many exceptions. For example, anti-Vel, -P, and -PP1Pk (-Tja) may react only at cold temperatures, yet may cause red cell destruction in vivo. Anti-Ch, -Rg, and many of the Knops and Cost antibodies have little or no clinical significance despite their reactivity by an IAT

finally

For some antibodies, few or no data exist, and the decision on clinical significance must be based on the premise that clinically significant antibodies are those active at 37 C, by an IAT, or both.

There are 2 tables that may be of benefit I have not pulled in here. Table in Chapter 14 of 16th ed of Technical Manual and Table 16-6 of same ed. Hope this sheds some light.

[generalist]

i found reference(AABB) to if you cant rule it out it was advisable to give antigen negative units, but nothing that states, anything about future rule outs.

[bduff]

I wouldn't say that you always have to give E neg cells. If you can rule it out then you don't have to bother but each time he gets blood that will change. If you can antigen type him that would be good. If he is E pos then you do not ever have to worry about anti-E. I hope that helps.

[generalist]

thanks for all your info ,but apparently we are going ahead with this policy "if you cant rule it out", a restriction will be put in the pt's file to always receive antigen negitive units to any and all antibodies that were unable to be ruled out. not sure of the reasoning behind this , but a sop is a sop. once again thanks for all your input

[L106]

generalist - One last comment. Have you discussed this with the lab that does your reference lab work (& provides you with special antigen-negative units)? It would be good to hear how they recommend these situations should be handled. If they do not support you policy/SOP, perhaps they could discuss it with the individual in charge of your transfusion department.

[ANORRIS]

So as long as our BB has a policy stating it is "ok" to use expired panels for rule outs and perform a QC it is fine with AABB & CAP? What do you do for a QC on these exp. panels?

[generalist]

redcross was the first people i called (our reference lab) they were in disagreement with it and were the ones that told us as we had ruled out E this time we didnt need to give antigen neg units to the pt, Our manager has called a friend who is?was a BB supervisor at a different hospital and was told that they had this policy in place, so now we are going with it also.

[generalist]

no qc is done on expired paanels, we dont have an sop for expired panels only a blurb at the end of our rule out sop that states to use them for aditional rule outs but not to be used only.

[Malcolm Needs ☆]

thanks for all your info ,but apparently we are going ahead with this policy "if you cant rule it out", a restriction will be put in the pt's file to always receive antigen negitive units to any and all antibodies that were unable to be ruled out. not sure of the reasoning behind this , but a sop is a sop. once again thanks for all your input

Oh dear, this is a dangerous and illogical road down which to go!

If you think about it, in the case of a patinet with a warm auto-immune haemolytic anaemia, where there is free auto-antibody in the plasma, there are few ways of telling, for certain, whether or not the plasma contains antibodies against "normal" (for want of a better phrase) antigens. One of these is to perform auto-adsorption, but this can only be done if there are sufficient autologous red cells available, and if the patient has not been transfused within the previous three months.

If not, then something like differential alloadsorption must be performed, BUT, if this is done, one cannot rule out such antibodies as anti-Vel, anti-Lan, anti-Kpb, etc, etc.

Your policy (well, not your policy, but the policy adopted by your place of work) means that, logically, all units must be Vel-, Lan-, Kp(b-), etc, etc.

It cannot be done for those antigens, and I see no reason for it to be done for others (such as E) under the particular circumstances you have described in your previous posts.

:(:(

Edited May 25, 2010 by Malcolm Needs
Spelling (yet again)!

[generalist]

one can only hope this policy will not come back to bite us .as we are a small lab most problem pt's will go to our reference lab, so we will probably end up doing only simple id 's but i bet we have a lot of this with unable to rule out E .

[adiescast]

I don't see that your blood supplier will long support that policy, particularly when you start getting a long history of various antibodies not ruling out on one occasion or another (even if you don't go to Malcolm's extreme, with adsorptions you can see many failures to rule out). What happens when the reference lab can't rule something out this time? Does it go on the list too?

I am surprised that your manager did not consult more than one source to make this decision.

[Malcolm Needs ☆]

I am surprised that your manager did not consult more than one source to make this decision.

You are? Sounds to me like he/she is a manager, rather than a Blood Banker (which means that I am not).

Sorry to be so cynical.

:(:(

[LaraT23]

I also am very surprised ( and not surprised like Malcolm) at this decision. Even a manager non-blood banker can see the horrible potential delay of products, not to mention the HUGE expense this poses. I had a patient recently who has Jkb, C, S, and Fya. Her units cost us almost 800 each. Luckily for us, we were able to rule out most other things by antigen testing the patient. I cannot imagine what the expense would be per unit were we unable to rule out others. And, as Malcolm said, so antigens simply cannot be found negative on cells! Good Luck to you.

[L106]

I don't see that your blood supplier will long support that policy, particularly when you start getting a long history of various antibodies not ruling out on one occasion or another (even if you don't go to Malcolm's extreme, with adsorptions you can see many failures to rule out). What happens when the reference lab can't rule something out this time? Does it go on the list too?

I am surprised that your manager did not consult more than one source to make this decision.

I am in total agreement with you, adiescast. I bet the reference lab will eventually put their foot down when they receive the request for donor blood that is negative for a dozen antigen (because they couldn't be "ruled-out.")

I strongly suspect that there was some type of misunderstanding somewhere along the line. Maybe "generalist's" manager didn't explain the situation correctly to his/her BB supervisor friend, or maybe the manager misunderstood the BB supervisor friend's suggestion of how it should be handled.