Hmmmm...its probably a COLD AUTO

[RL0121]

A weekend Antibody workup was sitting in my desk waiting to be reviewed this morning. Night CLS told me she has no time to review the workup from the previous shift. Patient with no previous transfusion hx came in and was scheduled today for surgery. In other words..yes, there's 2 units xmatched for this patient. No Antibody ID was reported out and looks like the tech perform LISS tube screen and xmatch. M,S was ruled out using LISS. K wasnt ruled out but he performed cold panel at 4 C 15 mins and was positive. Auto neg but DAT was performed (Neg). There's a note for me to complete the ABID report as Cold. I was able to R/O M,S and K by recrossmatch the units by gel method. ABID was reported as INCONCLUSIVE ( give gel xmatch compatible units). My pathologist ok'd it. How am I going to approach the CLS who has gazillon years of experience ? My concern was: Why proceed to LISS screen and xmatch and assume that its cold? And why crossmatch the units without completing the ID. Please advise..

[Malcolm Needs ☆]

This may sound a daft question, but what was the ABO group of the patient, and were the units the same ABO group, or were they a compatible, but different ABO group?

[RL0121]

Malcolm,

ABO compatible units (O+) were xmatched. At the end of the day, I found out there's no consistency among the CLS's when ruling out antibodies. Some techs will perform gel using the PANOCELL 3% selected cells, and the rest prefers LISS method. As outlined in their current SOP, when Panocell 3% is used to exclude antibodies, LISS method is followed and not gel. Cold screen is + at 4 C , 15 mins, DAT=neg, auto neg, all clinically significant antibodies were r/o. He noted CAA to be reported. I'm lost Malcolm. We reported it out as Inconclusive and gel xmatch compatible units were given to the patient.

[Malcolm Needs ☆]

Hmmmmmmm, I see your point.

I was just wondering if the patient was a group A, B or AB, and that the screening cells, panel cells and units were group O. If that had been the case, it could well have been that the antibody concerned could have been an auto-anti-H or auto-anti-HI, reacting preferentially with group O cells (with their higher expression of the H antigen), but "apparently" not with self. From what you say, this does not appear to be the case.

I'll have another think.

[Malcolm Needs ☆]

Forgive me for asking more questions RL0121, but I am not familiar with the screening cells and panel cells you use.

If you were able to rule out certain specificities (anti-M and anti-S and, eventually, anti-K), does this mean that some of the cells in the screen and panel gave negative results? If so, I am just wondering if this could be an anti-P1. Not all anti-P1's react with all P1 positive red cells, as the strength of the expression of the antigen varies widely from one individual to another, and, as I say, not being familiar with your screening and panel cells, it may be that this is not reflected. I know that some of our own panels show this variation, with P1+ cells being "scored" from 1 to 4, whilst other panels we use just put them as positive or negative (not helpful!!!!).

[ABIDer]

Are the techs diluting the 3% Panocells when using gel? They may be using Liss in tube since 0.8% is needed for gel. Do you a 0.8% panel?

[RL0121]

No, they're not suppose to dilute the 3% Panocell according to their procedure. They use it for tube LISS. INCONCLUSIVE reporting is not a practice so I see a lot of COLD SCREEN being done.

[Rh-fan]

I do not like "cold" antibodies when the auto controle is negative. In these cases I want to know the specificity before I change to a different methode and give negative Xmatch.

Peter

[RL0121]

I hear ya Peter. I feel better if my units were gel xm compatible instead of Pre warming them away.

[mhc]

Malcolm,

ABO compatible units (O+) were xmatched. At the end of the day, I found out there's no consistency among the CLS's when ruling out antibodies. Some techs will perform gel using the PANOCELL 3% selected cells, and the rest prefers LISS method. As outlined in their current SOP, when Panocell 3% is used to exclude antibodies, LISS method is followed and not gel. Cold screen is + at 4 C , 15 mins, DAT=neg, auto neg, all clinically significant antibodies were r/o. He noted CAA to be reported. I'm lost Malcolm. We reported it out as Inconclusive and gel xmatch compatible units were given to the patient.

Sounds like you need to develop an algorithm for working up problems. You should not leave it to the CLS's to do whatever they want.

[RL0121]

It's only my 3rd week in the facility and in the process of getting to know everyone. I know what you mean about developing a system how to work up an antibody. Majority of the techs know their BB by heart. Thanks for your input mhc .

[jill]

With a + reaction after 4C for 15 minutes this is most likely not a cold agglutinin. (Incubation time of 30

minutes at 4C is used in our lab.) Was the positive screen originally seen in gel?

[RL0121]

Yes. 2 out of 3 of 1+ reaction. They're not allowed to report inconclusive. If everything is ruled out and a gel xmatch Unit is compatible why spend more time with extra work? Cold Screen seems the preffered method . Can someone validate this with me so I can work on changing our process. Antibody screen pos , selected panel ID neg , auto neg, all clinically significant antibodies were ruled out. Back where I came from this will be reported as INCONCLUSIVE and gel xmatch compatible units is recommended. I'm curious about what other blood bankers will say.

[Barbarakym]

I have to say, are you the supervisor? If so I think you have more problems than just the ABID.

My suggestions:

1. Review procedure. Make sure you have designated flow of work. Ex my procedure says: A. PRIMARY process is gel. All work starts with GEL. If there is an antibody gel panel is performed. Rule out must be by gel. Period. Techs don't have a choice.

B. If mf on gel for ABS ( common with colds with gel): procedure States to go to tube. (loss). Now all work is tube. No jumping around. Tube is 3 phase. All must be done. Including AC.

C. If there is reaction at IS at RT a cold is ID. There could be something else as well. But cold is there. If auto is neg= cold agglutinin, pos=. cold auto.

All 3 phases must be complete. If AHG is neg then ABID only cold. If AHG is positive another I'd possible.

Gel is more sensitive than gel. You can have a kell on hell and it might not show in tube tell you give another kell positive unit. Be careful of allowing people to pick what gets rid of the reactions. ABID should have clear procedure.

My point is your procedure must standardize your techniques. Make everyone follow whichever work flow you have decided is primary. Have clear branch with its own path for any deviation. Good Luck.

[RL0121]

Your feedback was very helpful Barbara. I know I have a lot to learn since this is my first time to supervise a blood bank facility . I'm very confident as a BB Tech but since im evaluating their current workflow process, there are of course gray areas that needs attention. Im mentally challenged because I don't have anyone training me for the job. Although the previous supervisor is just a phone call away I don't want to annoy her. The senior tech that was supposed to train me is on vacation for 3 weeks. When she comes back she also work in different areas in the lab. Without BB Talk I will be lost .

[Barbarakym]

Some typos in my reply . Window so small on I phone.

Bloodbank talk has helped me immensely. And I have a couple decades experience as a BB tech. But only a few years as lead and 2 as super. When I came here I had much same problem. But if you are in us you can fall back on inspection to blame for insisting people follow procedure. TJC & AABB insist you have a procedure and that every one follows it. So to get everyone on board write a clear procedures telling people how to proceed. Be clear and specific and treat everyone exactly the same.

To determine procedure there will be lots of advise. But remember if your choices are gel and tube you need to pick a primary. And then rules on when to transistion to the secondary. And on previous post I meant to say gel is more sensitive than TUBE. So weak 1+ gel will often be neg on tube. But that does not mean its not there. As we found out once with kell.

[RL0121]

Agree 100%. In Blood Bank, uniformity/consistency is followed. When I was just a new BB CLS, someone took over the department in the facility I work. She changed the way things are done. Its a whole BB make over and those changes are very good although not everyone's on board at first, eventually the process took place and the rules are followed.

[Gnapplec]

Forgive me not knowing the details of what reactivity was seen but I am alarmed by the fact that the CLS decided twice to perform testing that was not indicated in my opinion. First if the auto control is Negative, why the DAT, and second if the DAT is negative why go to a cold screen? Our process deters us from doing cold screens willy nilly and there needs to be a pos AC and pos C3 on the DAT.... we absolutely can’t “just call it a cold” Similar to what Rh-fan posted above: I also don’t like the fact that the auto control was Negative and somehow a different method was started". In my opinion reporting “nonspecific reacting antibody of unknown specificity” is more ok in our lab vs. “just calling it a cold” ....Best of luck in re-vamping your workflow.

Edited April 13, 2012 by Gnapplec