New Specimen after transfusion of 10 or more PRBC

[BBgail]

When I was on bench, which very sadly I am not now, when a patient was transfused with 10 units of PRBC within a 24 hour period, we required a new specimen be obtained and used for any additional crossmatches. I know Standards says a Blood Bank/Transfusion service needs to have a policy regarding compatibility testing when a patient has received, within 24 hours, an amount of blood approximating total blood volume and states no other requirement. Before I update the policy here, I'd like to get an idea of policies/thoughts from fellow BBers.

Thanks!

[David Saikin]

I don't see the need for a new spec - which is NOT the patient's blood - wait the 3 days.

[Malcolm Needs ☆]

I agree with David.

This is certainly what we did, back in the Dark Ages, when I used to work in a hospital.

[rwalter]

It's my understanding that once you go into the massive transfusion scenario, the standard allows you to do "abbreviated" compatibility testing. In our facility, once we are past the first ten RBC units, we go to handing out type compatible blood that is not serologically crossmatched. The IS crossmatch on the original sample is pretty much meaningless at that point. We get a new sample after three days.

[dgibaud]

You might want to crossmatch with a new specimen if you're restarting the patient's correct ABO after 10+ units of O. This is more of a problem if you're using whole blood, or for smaller patients.

[John C. Staley]

The only reason I can see for getting a new sample in this case would be if you have used up all the original sample. As rwalter stated, back in the day, we could go to an abbreviated crossmatch under these circumstances but for the most part most everyone is already doing "abbreviated" crossmatches routinely. There is no need to collect a new sample simply because your patient used a lot of blood in a short period of time.

[Abdulhameed Al-Attas]

I agree with John,

unless you want to switch back to group specific after 10 units of group O, in that case ,you need a new sample

and a full X-match including Antihuman globulin phase. If it is incompatible then NO switching, continue transfusing

group O.

[Likewine99]

I agree with David. I had a conversation with our Trauma Surgeon once upon a time and he'd read in his journals that in the massive tx scenario, the pts immune system "shuts down" due to the fact that there is so much other stuff going on physiologically.

The last thing this patients body has to worry about is developing antibodies and the blood is zipping through them so fast they probably wouldn't have time to make an antibody anyway.

[Deny Morlino]

I agree with David. I had a conversation with our Trauma Surgeon once upon a time and he'd read in his journals that in the massive tx scenario, the pts immune system "shuts down" due to the fact that there is so much other stuff going on physiologically.

The last thing this patients body has to worry about is developing antibodies and the blood is zipping through them so fast they probably wouldn't have time to make an antibody anyway.

This has been my understanding as well.

[CM2]

Agree with likewine. We depend on this quirk in RH neg massive bleeder scenarios where our policy is to switch to RH pos during the bleedout event, switching back to Rh neg once the crisis is over. If this wasnt the case, Id think we'd have a huge issue with patients developing anti-D and delayed hemolysis a few weeks after, yet it doesnt seem to happen. Id also mention ppl who get 10 units rbcs tend to start getting plasma and platelets as well at that stage, so the plasma youre drawing to retest is that much less likely to reflect the patients actual immune status.

[L106]

I don't see the need for a new spec - which is NOT the patient's blood - wait the 3 days.

This is our policy also.

[adiescast]

We wait the three days (unless they cut off the armband!). No use in testing donor blood.

[Mabel Adams]

I'd rather have the patient's original sample. It represents his immune system and will continue to do so until the 3 days are up. It also probably represents his ABO type better than after a full exchange and since this is the whole reason for the IS xm I would stay with the original specimen. Now with electronic xm, much of that is moot anyway. One issue would be patient ID. Some places get a new sample once they have updated from John Doe or equivalent but I even think with the traceability of ID in a computer that this may not be necessary.

[sblanchard]

Agree w/ Mabel. Electronic crossmatch is awesome for eligible pts. Well worth validating if your computer system can support it. This eliminates specimen volume questions and saves segments for full xms.

[David Saikin]

One kudo to all this: I have seen massive tranfusion of the incorrect ABO type: pt rec'd 16 B+rbcs and 22 B plasmas - then was transferred to our hospital. Typed as a B+. 4 days later rbcs were ordered - pt typed as Bmf Rh pos mf: the mf cells were O neg. Patient was O neg - bili went from 2 to 31 in 16 hrs; pt expired from massive hemolysis. Get it right the 1st time. (MD drawing blood in ED and labeling after the fact - BB tech at referring hosp lost job as pt was in their file as O neg).

[bmarotto]

Great point, David. It sounds like the referring hospital did not have a BB computer system at the time and the tech just went with the type of the sample instead of checking the file. I wonder what was done about the MD who drew the blood. It has always bothered me when there is a different level of accountability depending on your position.

[Eoin]

Hiho,

Agree with all that has been said. We would wait the three days - abreviated testing after 10 units - why have a specimen full of who knows what?

Cheers

Eoin :cool:

[tkakin]

It's my understanding that once you go into the massive transfusion scenario, the standard allows you to do "abbreviated" compatibility testing. In our facility, once we are past the first ten RBC units, we go to handing out type compatible blood that is not serologically crossmatched. The IS crossmatch on the original sample is pretty much meaningless at that point. We get a new sample after three days.

I don't understand what you mean by abbreviated compatibility testing. I thought it is the type and screen with an IS crossmatch. Do you do electronic xms?

[rwalter]

In this case, many facilities go from doing IS crossmatch to simply issuing ABO compatible RBC units, with no crossmatch at all. The premise is that testing against the original sample has no real value, as whatever is circulating in the patient now has little resemblance to the original.

[Mabel Adams]

Teresa, that old rule dates back to the days when we did AHG xms on every unit--except for the situation described. Apparently some places adapted it to the IS xm world. The key thing is knowing that you are passing out units that will be ABO compatible.

David, I remember reading of a similar story that also involved a transfer to a bigger hospital of an O patient typed as B due to mistransfusion at the prior hospital. I use it as a story to tell trainees why noticing mixed field in blood types and getting as much history as possible is important.

[Auntie-D]

One kudo to all this: I have seen massive tranfusion of the incorrect ABO type: pt rec'd 16 B+rbcs and 22 B plasmas - then was transferred to our hospital. Typed as a B+. 4 days later rbcs were ordered - pt typed as Bmf Rh pos mf: the mf cells were O neg. Patient was O neg - bili went from 2 to 31 in 16 hrs; pt expired from massive hemolysis. Get it right the 1st time. (MD drawing blood in ED and labeling after the fact - BB tech at referring hosp lost job as pt was in their file as O neg).

I've read that one on the SABRE/SHOT webiste of example cases!! Scary stuff!

Everywhere I have worked it has been that after 10 units no comaptibility testing is required (unless changing back to the patient's own ABO). A fresh sample is drawn after 3 days.

I've never had a situation where we have run out of sample for a massive transfusion - there is usually plenty of plasma to xm 10 units. If the patient had a positive antibody screen and you were empirically crossmatching I could see you might run out here.

[JOANBALONE]

When I was on bench, which very sadly I am not now, when a patient was transfused with 10 units of PRBC within a 24 hour period, we required a new specimen be obtained and used for any additional crossmatches. I know Standards says a Blood Bank/Transfusion service needs to have a policy regarding compatibility testing when a patient has received, within 24 hours, an amount of blood approximating total blood volume and states no other requirement. Before I update the policy here, I'd like to get an idea of policies/thoughts from fellow BBers.

Thanks!

I think this policy is from the days when red cell units contained a lot of plasma. These days, the red cells in use contain Adsol or other additives, very little plasma is left. I have not seen any passive isoagglutinin due to transfusing massive amounts of group O blood in many years. I have seen it when transfusing incompatible platelets/cryo.

JB