Blood Requests after a Transfusion Reaction Workup

[goodchild 529]

Consider that a transfusion reaction workup has completed and no evidence of hemolysis was noted.

The medical director or designee has been contacted and provided their evaluation and further transfusion is acceptable.

 

If additional RBCs need to be issued for the patient do you...

 

• Continue to use the original type and screen for crossmatching RBCs?
• Use the post-transfusion reaction specimen for crossmatching?
• Use the post-transfusion reaction specimen for crossmatching after it's had an antibody screen tested?
• Any orther sort of scenario?

 

We have an extensive initial phase transfusion reaction workup that I'm not entirely happy with:

 

• Clerical check
• Visual inspection of infusion set/blood product
• Visual inspection for evidence of hemolysis
• DAT on post-specimen
• Post-specimen ABO/Rh and antibody screen
• IAT XM of RBC units transfused with post-specimen
• UA

Edited August 7, 2015 by goodchild

[R1R2 304]

No DAT?

[goodchild 529]

No DAT?

 

Whoops! Yes, edited the DAT back in there.

[SMILLER 870]

We do the first five things on your list.  In general, if the DAT is negative, we let the transfusion continue if the attending wants it restarted. 

If more units are needed, we use the original specimen as long as the screen is not outdated.

 

Otherwise, with a true transfusion reaction, the pathologist gets involved and we end up doing a haptoglobin, plasma hemoglobin, etc. (Of course, the unit is not allowed to be restarted.)  We would end up repeating the Type and screen and an eluate from the positive DAT.

 

Scott

[Liz0316 57]

We do the first 4 items, and the ABO/Rh on the post sample. We only do the A/S if we are going to continue with transfusions.... using the post sample for the new T&S. (provided no results are abnormal and it's not a hemolytic reactions). Liz

[R1R2 304]

we do everything except post screen, XM and UA. We continue to use pre sample unless something is found in the post.   

[Auntie-D 363]

This is the double-sided form I developed. One side for them and one for us... All tests can be recorded on it

Transfusion_Reaction_Form.doc

[Dr. Pepper 910]

Ditto to R1R2. If the patient needs more blood, we use the original spec. If we need to use the post-rxn spec over the next 3 days, we will do a screen on that spec and proceed as with any other.

 

If the patient needs more blood before the initial investigation is completed, we get a release from the MD. If it shows no evidence of hemolysis, we proceed as above. If it does (pos DAT, say) we get a release if the patient needs more blood before we complete a comprehensive exam.

[goodchild 529]

Thanks for the responses everyone. Anyone else willing to weigh in?

 

Right now we use the post-transfusion specimen because we're doing an antibody screen with every workup. I'd like to eliminate the post-ABS and post-XM from the first phase of the workup and continue to use the pre-tx specimen for crossmatching.

 

I anticipate resistance so I'm curious of the 'generally accepted practice standard' in our blood banking community.

[Auntie-D 363]

By elimiating the post antibody screen, aren't you removing the chance of detecting an increase in titre of an unidentified antibody that was too low to identify, but the titre now has risen post blood? Anti-E particularly could be missed.

[SMILLER 870]

If the DAT is negative, I would think that a post screen would be unecessary, as there was no transfusion reaction to begin with, hence nothing to stimulate any particular antibody.  (Theoretically I suppose, any transfusion may result in an "increase in titer", but no one does a screen after every uneventful transfusion.)

 

Scott

[goodchild 529]

By elimiating the post antibody screen, aren't you removing the chance of detecting an increase in titre of an unidentified antibody that was too low to identify, but the titre now has risen post blood? Anti-E particularly could be missed.

 

What does the BCSH indicate for transfusion reaction investigations in the blood bank?

[izzyfig 2]

In our transfusion service, a transfusion reaction may be called by either a PA/NP or the physician. Never by the nurse. We always double check what provider's name will be on the documentation before we confirm a reaction. We do everything mentioned except perform a IAT XM with the post, unless the patient needed the extended XM on the pre sample. We also look for hemolysis pre vs post sample and have the floor send back all blood products that the patient may have there. 

 

In addition, we forward type all RBC units and reverse type platelets and FFP to confirm the original types on the units. Also if the patient has an increase of temperature by one degree centigrade at any point during the transfusion, we send all transfused product bags to micro for culture. 

 

If the post sample has a positive DAT we also perform a DAT on the pre sample. If they happen to be both positive, well then we're doing two elutions... If the patient is going to need additional transfusions, we will not release any products until the entire workup is complete, unless our transfusion physician approves of it. Which that almost never happens. 

[Brenda K Hutson 195]

Consider that a transfusion reaction workup has completed and no evidence of hemolysis was noted.

The medical director or designee has been contacted and provided their evaluation and further transfusion is acceptable.

 

If additional RBCs need to be issued for the patient do you...Coincidentally, I just recently sent an e-mail to a previous medical director where I worked, asking this exact question (because where I work now, does it differently).

 

• Continue to use the original type and screen for crossmatching RBCs? Yes, provided it was not a hemolytic transfusion reaction
• Use the post-transfusion reaction specimen for crossmatching? That is what we do where I currently work....but I am going to change that
• Use the post-transfusion reaction specimen for crossmatching after it's had an antibody screen tested? If I am going to use the post-transfusion specimen for my crossmatch, then I would also perform a Type & Screen on that specimen.
• Any orther sort of scenario?

Brenda

[mollyredone 318]

If the pre and post DAT are both positive, do you always assume it is transfusion related?  What if the pre antibody screen is negative?  Do you look for medications that might cause a positive DAT?  We don't do elutions here and it would really delay future transfusions if we had to send both specimens out.  I know I can get approval for high risk transfusions if the medical director okays it.  AABB standards state that if the post DAT is positive to perform a DAT on the most recent pre sample, but they don't say what to do after that.  Does anyone check for icterus on the post sample?  Our current policy states to check for icterus if it has been 5-7 hours post transfusion.

[Carrie Easley 82]

Our basic post-transfusion work up includes clerical check, hemolysis check (pre & post), icterus check (pre & post), post ABO/Rh, post DAT, pre DAT if post was +, elution if the post DAT is stronger than pre. Additional testing is ordered if any of these results dictate.  A blood culture of the bag is requested if there is unexplained hemolysis in the recipient, or when a fever greater than or equal to 39 degrees C. or an increase in temperature of at least 2 degrees C over pre-transfusion temperature is reported.

We encourage and constantly educate nurses to identify and call transfusion reactions.  We have found that physicians tend to be dismissive, and want the unit continued.  An area hospital actually transfused the entirety of a contaminated platelet because the physician paused, gave Tylenol, and continued the unit.  The patient died.

Hives/urticarial only requires clerical check.  We require pathologist OK prior to issuing another unit. The only time we will allow a transfusion to continue is if hive/urticaria are the only symptoms. 

We continue using the original specimen for crossmatch.

[goodchild 529]

39 minutes ago, CarrieM said:

An area hospital actually transfused the entirety of a contaminated platelet because the physician paused, gave Tylenol, and continued the unit.  The patient died.

That's certainly terrifying. Thank you for sharing.

[Auntie-D 363]

We have a double sided form to follow - one side for the ward, one for the lab

Transfusion_Reaction_Form rbh.doc