Incompatible crossmatch due to warm auto or htla

[jalomahe]

How do you handle incompatible crossmatches due to the patient having a Warm Auto (work up performed by reference lab so you only have neat plasma to do the xm with) or a HTLA? How do you report the crossmatch interpretation? Do you make any special notification to the MD? Do you require the MD to sign a form stating they understand that the blood is incompatible?

Thanks for any and all input.

[KKidd]

We have the Meditech computer system and can enter "L" as the interpretation of a XM. This means that it is "least incompatible" and can be issued to the patient in the computer. We discuss the situation with the doctor and give him/her the options. The doctor must sign a release form prior to transfusion.

:movingon::movingon::boogie::boogie::boogie:

[Malcolm Needs ☆]

When we do the cross-match for the hospital, we issue the blood as "suitable", rather than "compatible", and issue a warning that, under such circumstances, the observations during the transfusion are of paramount importance - not that they aren't anyway.

[Laurie Underwood]

We result the XM as Least Incompatible. We have a form which covers Warm Auto, unidentified antibodies, which they still want to transfuse the patient, and instances where we lack the antisera to antigen type the unit but the unit is compatible. We do call the MD. They will sign the form, if they are in the hospital, before transfusion. If the MD is not available, the MD will give a telephone order to our RN house supervisor, who will sign the form so the patient can get transfused. The MD still needs to sign the form within 24 hrs.

[L106]

Sometimes with HTLA or weak autoantibodies, we are able to find a couple donor units that look compatible. However, if we don't have that good fortune, we report the crossmatch as "Incompatible." We notify the physician, and if he still wants to transfuse the patient, we have a form he must sign that acknowledges that he has been informed of the situation and has decided that the transfusion is absolutely necessary (and the benefits outweigh the risks.)

Similar to Laurie's post, we have different sections of the form that specify that the donor unit is: 1. Incompatible 2. Compatible, but the pt's antibody has not been identified. 3. Compatible, but has not been tested for the corresponding antigen. If the doctor is not physically here (or can't sign because he's doing surgery, etc), he can authorize a nurse to sign his name for him (and she co-signs.)

Donna

[Yanxia]

In this situation, we will not recrossmatch the units, because we can't do adsorption test, the units with the neat plasma is incompatible. We will retest the ABO and RhD antigen of the donor and the recipient to prove they are the correct one. And on the sheet we give the physician we will write as the reference lab give us such as only used as saving life and be cautious when transfusion ,and sign the name of the reference lab technician.

[David Saikin]

If we can autoabsorb out the auto and get compatible units we report them as compatible with absorbed plasma. The docs still sign for incompatible with the nature of the incompatiblitly being an autoab. Our Med Director likes the invivo xm for these situations.

[JMunden]

We give units which are antigen profiled to patient whenever possible, to prevent alloimmunization; In addition to issuing as Least Incompatible with the physician signing a responsibility release.

[David Saikin]

Thanks - I give Rh phenotype specific if possible . . .

We give units which are antigen profiled to patient whenever possible, to prevent alloimmunization; In addition to issuing as Least Incompatible with the physician signing a responsibility release.

[tbostock]

We report them as incompatible and have the MD sign with a strongly worded statement about "not able to rule out alloantibodies....". They never seem to have a problem signing...amazing to me.

[Liz]

We report them as incompatible and have the MD sign with a strongly worded statement about "not able to rule out alloantibodies....". They never seem to have a problem signing...amazing to me.

hahahahaha, Indeed, truly amazing.

So what amazes me now is when one actually stops, considers and then says "no, I'd rather wait"... great MD in my eyes. (then comes the thought...so what was the rush about??).

[jcdayaz]

We have an option in our computer system to enter "Least Incompatible" in our crossmatch result section. We then contact the physician and require a new order to be written and sent to us by him/her for "Least Incompatible Blood" to be transfused. This has to be ok'd by our Blood Bank Medical Director prior to issuing any blood for the patient.

That's how we do it. Good luck!

[glewis]

We also result as "least incompatible". Our Medical Director contacts the ordering physician personally prior to the transfusion. If the physician decides to transfuse, the Medical Director and a Transfusion Service staff member deliver the first unit of blood to the patient's room and explain the risks to the patient and nurse transfusing. I would love to have a copy of the forms that are signed by the physician, since we do not use any documentation for all of this activity. Thanks

[jayinsat]

we call it least incompatible, give phenotypically matched (as much as is feasible-at minimum rH, Kell, Kidd and Duffy) and have them sign a form.

[Winter]

We also use Meditech and can result as least incompatible (L).

Currently I have 2 patients with WAIHA. The first is e negative (surprise!) but has an auto-E as confirmed by our reference lab. Which do we choose? The gel crossmatches are all 3+; the LISS tube crossmatches are 4+ with Rh positive and 2-3+ with Rh negative. The docs are holding at the moment since she has a 7 gm hgb. I haven't yet phenotyped our stock.

The second patient is an outpatient needing hip replacement (second time). Our reference lab phenotyped him for us in January. He is E, c, Jka, Fyb and s negative. I know the statistics for finding phenotypically matched blood, but I don't see any other choice!

What would you do?

[jcdayaz]

We also use Meditech and can result as least incompatible (L).

Currently I have 2 patients with WAIHA. The first is e negative (surprise!) but has an auto-E as confirmed by our reference lab. Which do we choose? The gel crossmatches are all 3+; the LISS tube crossmatches are 4+ with Rh positive and 2-3+ with Rh negative. The docs are holding at the moment since she has a 7 gm hgb. I haven't yet phenotyped our stock.

The second patient is an outpatient needing hip replacement (second time). Our reference lab phenotyped him for us in January. He is E, c, Jka, Fyb and s negative. I know the statistics for finding phenotypically matched blood, but I don't see any other choice!

What would you do?

Good luck finding an E,e negative unit to transfuse in situation #1 you describe here. If it were me and the patient absolutely HAD to be transfused right now, which it sounds like she/he doesn't, I would go with E negative blood. It sounds like the e is a possibility, but not present yet. Yes, it's rolling the dice, so to speak, but what options do you have? In this situation we would call the attending physician and "Strongly Urge" the use of steroids to try to get the Auto antibody under control. Obviously we can't prescribe medicines, but we can "Suggest" their use when appropriate. The Doc's are normally very receptive to our "Suggestions". We have a patient that comes in from time to time that has the exact same scenerio. Sometimes when her Auto is strong enough, we just simply tell the Doctor there is no compatible blood and he/she will have to sign an Emergency release form for incompatible blood. Then it has to be OK'd by our Medical Director who has to sign the emergency release form also. He will call the attending physician personally prior to signing the form to ascertain true medical need. It's a pain, but sometimes what choice do you have? We have done this probably only twice in my years at my current facility. Odd how the urgent need for blood becomes a little less urgent when a MD has to put his/her signiture on a legal document.

[Malcolm Needs ☆]

We also use Meditech and can result as least incompatible (L).

Currently I have 2 patients with WAIHA. The first is e negative (surprise!) but has an auto-E as confirmed by our reference lab. Which do we choose? The gel crossmatches are all 3+; the LISS tube crossmatches are 4+ with Rh positive and 2-3+ with Rh negative. The docs are holding at the moment since she has a 7 gm hgb. I haven't yet phenotyped our stock.

The second patient is an outpatient needing hip replacement (second time). Our reference lab phenotyped him for us in January. He is E, c, Jka, Fyb and s negative. I know the statistics for finding phenotypically matched blood, but I don't see any other choice!

What would you do?

Given that almost all of these "auto-anti-E" and "auto-anti-e" antibodies are mimicking specificities, and that the quoted "auto-anti-E" and "auto-anti-e" are actually "auto-anti-E-like" and "auto-anti-e-like" specificities (but NO Reference Laboratory is going to prove this nowadays by using extremely rare red cells [why re-invent the wheel], including mine, and the IBGRL [and, I would suggest, that run by George Garratty]), it is safe to ignore these auto-antibodies, unless antigen positive blood (i.e. E+ or e+) suddenly become so short-lived after transfusion that they are no longer an option. Most of what you are seeing are either anti-Rh17 or anti-Rh18 - and you are NOT going to find units that are negative for these antigens, except in frozen rare blood banks.

Do not worry. Give antigen positive blood, if the individual needs blood.

[adiescast]

The other problem with honoring an auto antibody with mimicking characteristics comes in patients that are negative for the companion antigen. If they are e negative with an "auto anti-E" I would truly hesitate to give them E negative blood unless they were not responding well. I'm with Malcolm.

We actually started calling these units "incompatible" rather than "least incompatible." Most of the time there is no "least" to it with a warm auto antibody. They are all the same...incompatible. I want the doctors to know what they are giving and not get too complacent about it.

Edited July 5, 2011 by adiescast

[Liz]

We also use Meditech and can result as least incompatible (L).

Currently I have 2 patients with WAIHA. The first is e negative (surprise!) but has an auto-E as confirmed by our reference lab. Which do we choose? The gel crossmatches are all 3+; the LISS tube crossmatches are 4+ with Rh positive and 2-3+ with Rh negative. The docs are holding at the moment since she has a 7 gm hgb. I haven't yet phenotyped our stock.

The second patient is an outpatient needing hip replacement (second time). Our reference lab phenotyped him for us in January. He is E, c, Jka, Fyb and s negative. I know the statistics for finding phenotypically matched blood, but I don't see any other choice!

What would you do?

Please tell us what you released (if you did) and the patient's response (Hct, Hgb).

Thank you

[Linda0623]

We are also trying to set a policy for the handling of patients with either htla's or auto-antibodies that require transfusion as our patient population is largely geriatric and they are predominently orthopedic surgery candidates. Our patient acuity has been trending high for the last fiscal year, so we are seeing this more and more, and everyone's comfort level from anesthesia to the RN's responsible for hanging the blood are more than a bit put off by the idea of transfusinf incompatible blood. As part of our policy and education process, we too would like to have an urgent release form of some type as well as a consultant MD review, whether it be a hematologist or medical director review or approval that would cover the current admission.

Does anyone have a specific release form and/or policy regarding the review/release of incompatible blood that they would be willing to share here or to email to me at llevinus@caregroup.harvard.edu? Many thanks in advance

[Winter]

Our first patient was treated with steroids for 2 weeks and discharged with a 8.1 hgb, 24.8 hct and 6.3 retic. No blood was given.

The second patient has been treated with erythropoiten(sp?) and is scheduled for removal of an infected hip prosthesis tomorrow. His daughter was willing to donate but was ABO incompatible. I'll keep you posted.

[AMcCord]

hahahahaha, Indeed, truly amazing.

So what amazes me now is when one actually stops, considers and then says "no, I'd rather wait"... great MD in my eyes. (then comes the thought...so what was the rush about??).

It seems like around here that the Heme/Onc says "I'll wait" and Internal Med folks sign without blinking. I guess that shows a difference in depth of knowledge.

[AMcCord]

I am also interested in the form everyone is using for releasing incompatible units for transfusion. We don't have one, but feel the need to develop one. Would any of you be so kind as to post a copy on this thread? Thanks.

[Deny Morlino]

Here is the form we use:

BB-320A.DOC

[L106]

Thanks, Deny.