I feel like I was just struck by a blinding flash of the obvious with a little dash of "we've always done it that way."
When we do an elution, we perform an antibody screen with the eluate and the last wash, and an antibody ID panel for positives (or selected cells in rare cases when a lower incidence antibody is considered).
86860 is to cover the process that makes the elution; are we completely failing to charge for the additional antibody screen and antibody ID?
68 y/o african american female presents to ED with severe abdominal pain and heavy vaginal bleeding. Imaging is performed and there's a significant concern for malignancy. Patient has a history of multiple pregnancies, three live births, unclear transfusion history. Labs: 5 g/dL hgb. elevated coags, negative antibody screen in gel.
Patient is transfused 4 RBCs during the first and second days of admission.
Day three the patient is transfused 2 FFP for a procedure.
Day ten the patient is tested for type and screen again for the upcoming OR case and the screen is 1+ positive in gel, three cell. The three cell is rr K+k+Fy(a+b-)Jk(a+b-)Le(a-b+)M+N+S-s+. The gel antibody panel was negative with a 1+ positive autocontrol. The DAT was 1+ positive by polyspecific and IgG. An acid elution was performed and found to be negative.
On day eleven the sample is tested for antibody screen in tubes with PEG and found to be negative. The antibody is reported as undetermined specificity, requiring IAT XMs. The patient is transfused 2 RBCs operatively.
On day twelve another RBC is transfused.
On day thirteen another RBC is transfused.
On day fifteen the patient is tested for type and screen again due to expiration and the screen is 2+ positive in gel, three cell, same lot as before. The gel antibody panel shows an obvious pattern with Jk(a). The autocontrol is still positive. The DAT is 1+ positive with poly, IgG and complement. The acid elution shows an obvious pattern with Jk(a). Segments from the transfused units are phenotyped for Jk(a) and 6 of 8 were antigen positive.
If you encountered a scenario like this in real-time, how would you have approached it, from a reviewers standpoint? e.g. would you have performed any additional testing with the day ten sample or would that have been appropriate per your facility's policies? would you have performed any repeat testing with the day ten or day fifteen samples?
How do facilities handle missed antibodies on automated testing platforms? What do you require before returning to using your automated method?By DaMaam
I realize that all automated systems will not catch all clinically significant antibodies as no automated system is perfect; however, when a clinically significant antibody is not detected on the antibody screen, I'm curious to know what actions facilities have taken before "trusting" the automated method again. Of course, any other recommendations on how you might address this type of situation would be most helpful.
One of my larger projects for the last few weeks has been to update our procedure for antibody identification.
Most of the individuals who have been involved in reviewing/validating the procedure seem pretty satisfied with it but some of the techs think it's too detailed in some regards and insufficiently detailed in others. I do have a habit of trying making very long procedures that cover as many bases as possible but at the same time I didn't want to make the procedure too rigid because antibodies don't always' follow the rules' and in some cases there's a lot of art and intuition to performing an antibody identification.
The procedure includes:
Notification of caregivers of delay in testing/rbc availability Documentation requirements Acquiring transfusion history Process for performing full/selected cell panels Process for performing exclusion analysis (rule outs) Algorithms with suggested methods to perform in the event that the basic rule outs aren't enough and/or the autocontrol is positive. Probability What common antibodies should be ruled out with every AB ID and what to do if unable to rule something out How antibodies to low incidence antigens are handled How we handle antibody of undetermined specificity How/when to use expired panel cells Directions for IRL consultation How to determine the clinical significance of usually insignificant antibodies (anti-M) And a chart demonstrating the likely clinical significance of antibodies in transfusion/pregnancy I'm curious if anyone would be willing to share their documented procedure. If anyone is interested in having a look at what we're working on, PM me.
Thanks in advance and happy Friday!!