Anti V and other antigens with no commercially available typing sera.

[KarenJ]

We had a crossmatch ordered on a new patient today and when I checked our blood center antibody registry I discovered that she had an anti V detected about 6 months ago at another facility. Of course my screen was negative, I had pulled 2 panel cells to see if the V was still reactive and coombs crossmatched my units. I had consulted the IRL and they said as long as the V can be demonstrated the crossmatch is valid.

So far so good, now for the problem. Our LIS is Sunquest and I could not override the antigen/antibody failure. Is it acceptable to call the units V negative based on the non reaction with the patients plasma? With some sort of disclaimer of course. Any help or advice will be greatle appreciated. Thanks, Karen

[Malcolm Needs ☆]

Yet another example of us working for computers, rather than computers working for us.

No, I don't think it is aceptable to say that the units are V-, although, by the sound of it, you have no alternative. There should be a security level at which the computer can be over-ridden.

All that having been said, anti-V has only ever been reported as causing mild, delayed haemolytic reactions, and so giving these units would almost certainly cause your patient no harm whatsoever, even if they were later found to be V+.

[Jane]

I used Sunquest (a few years ago) and I thought for all discrepancies you could set what level of user could override it or maybe if it can be overridden. This may require a maintenance change that you or someone at your facility should be able to make.

[Eagle Eye]

I am sure someone has access to override the warning. May be password is required or someone with higher previladge can remove the flag, issue unit and then put the flag back in.

[nicholst]

You can override this QA. You will just need to change the maintanence settings to allow this to happen. You can do this through the BMA function.

[tricore]

I am the IT analyst for our Sunquest Blood Bank Module. The antigen antibody discrepancy can be overridden by staff with the designated security level. The setting is BMA 10,6, In our system the overide security level for these two QA items is tech level. Tech level is the only level that can allocate RBCs. If it set higher than tech level it does create problems when no one with that security level is available. If the institution does not alow all techs to override antigen/antibody discrepancies there should probably be someone on each shift with the security level. However, this is problematic depending on staffing, level of competency, and training.

67. "Patient/unit attribute incompatibility"

If you use the linking functions this one must also be set with the required security level.

96. "Linked patient/unit attribute incompatibility"

Edited March 13, 2013 by tricore
incorrect security level

[goodchild]

I have no idea on Kansas state laws, who you are accredited through or what your procedures say; but, if you are supposed to select antigen negative units for transfusion and you're using the crossmatch to verify this, make sure you document the deviation. Just your friendly quality assurance reminder. :tongue:

[tricore]

The overrides in Sunquest require a reason. Hopefully the techs are entering the reason for the override. The supervisore or designee should be reviewing the QA report in SQ BBR 7 QA report. Also many places have a deviation log that the medical director is required to dign.

[R1R2]

I agree with Malcolm, you have no choice. Is this what your policy states? I don't think you need a disclaimer. Could you remove the code "anti V" in the patient's file and add a free text comment instead? This may take care of the QA failures.

Edited March 14, 2013 by R1R2
typos

[Malcolm Needs ☆]

Actually, KarenJ, it is not just a question of anti-V not being available commercially, but even Reference Laboratories are finding it difficult, if not impossible, to find a reliable, reagent grade, monospecific anti-V to test patients! In the UK now, even when we send suspected V+ cases to the International Blood Group Reference Laboratory for confirmation, they tend to do the confirmation by molecular techniques, rather than serological techniques, simply because a decent anti-V is not available.

[KarenJ]

Thanks to all for the help. I did check the maintenance in BMA and think I have it working correctly now. I put a lengthy comment in the patients file also. Karen

[kirkaw]

Malcom and R1R2, are you saying that anti-V is not clinically significant and Coombs crossmatch compatible blood is OK? We have a patient in whom our reference lab has identified anti-V and we have been ordering V negative blood. Is that necessary?

[Malcolm Needs ☆]

Hi kirkaw,

I do not know the "rules" that apply in your particular part of the world, but, certainly, in the UK we would give cross-match compatible blood in this situation, unless the anti-V is particularly strong.

Firstly, not all anti-V's reported are, actually, anti-V, as it has been found to be a very heterogeneous type of antibody when tested against various rare Rh phenotypes.

Secondly, Geoff Daniels reports in the 3rd Edition of his book "Human Blood Groups" (page 214) that "No clinically significant anti-VS or -V has been reported. Anti-VS and -V are usually reactive by an antiglobulin technique..."

Thirdly, Marion Reid, Christine Lomas-Francis and Martin Olsson report in the third edition of their book "The Blood Group Antigen FactsBook" that alloanti-V has only ever been implicated in mild, delayed haemolytic transfusion reactions (page 216).

Fourthly, given that anti-V was first described in 1955 and, although it is not a particularly common antibody, the V antigen is expressed on about 1% of the white donor population and about 30% of the Black donor population, one would have expected that several people with anti-V have been transfused with V+ blood over the years, but none have been reported to have caused a clinically significant haemolytic transfusion reaction (and, don't forget, anti-V is unlikely to be detected by normal antibody screening cells, and so it is likely that some individuals with anti-V have been transfused with V+ units issued by electronic issue, albeit that anti-V and anti-VS are usually found in mixtures of other specificities, rather than as single specificities).

I would, therefore, contend that blood found to be compatible by IAT cross-match would be quite safe to transfuse.

[kirkaw]

Thanks Malcolm...as always...very helpful.

[R1R2]

Malcom and R1R2, are you saying that anti-V is not clinically significant and Coombs crossmatch compatible blood is OK? We have a patient in whom our reference lab has identified anti-V and we have been ordering V negative blood. Is that necessary?

Our SOP states the anti V is clinically significant.  I agree with Malcolm's statements about anti V.  I will use V negative units if the blood center can provide them but if not I will give crossmatch compatible per SOP.  For reasons that Malcolm stated there is probably not a big rush to produce reagent anti V.  If you are concerned about giving V negative units, you could save aliquots of your paitent's plasma to use in the future in case the blood center can't provide V negative units and the anti V falls below detectable levels.   

[Malcolm Needs ☆]

I sort of agree with you R1R2, but also disagree.

 

I agree that you could save some of the patient's plasma, but I disagree that you can use that (unless it is reagent class) as a grouping reagent, and, in any case, you are then giving what is, in effect, cross-match compatible blood (unless you have some V+ red cells around to use as a positive control for the patient's stored plasma - which may have "gone off").

 

I'm not sure that I have made sense there, but I know what I mean!!!!!!!!!!!

[Winter]

In this situation, we would have the physician sign the release form that would state, "Crossmatch compatible, but no commercially available antiserum with which to test units for the V antigen."

[R1R2]

I sort of agree with you R1R2, but also disagree.

 

I agree that you could save some of the patient's plasma, but I disagree that you can use that (unless it is reagent class) as a grouping reagent, and, in any case, you are then giving what is, in effect, cross-match compatible blood (unless you have some V+ red cells around to use as a positive control for the patient's stored plasma - which may have "gone off").

 

I'm not sure that I have made sense there, but I know what I mean!!!!!!!!!!!

I know what you mean too.   We would get preapproval from med director and document how testing was performed if it deviated from SOP. 

[Mabel Adams]

Malcolm, you need this quote: "I thought what I meant."