More Issues around Uncrossmatched Products

[Brenda K Hutson]

Sorry ahead of time that this e-mail is long....I don't seem to know any other type of e-mail than long.....

I have worked in large Trauma Centers as well as medium and small sized Hospitals that were not trauma centers but might get the occasional "trauma" patient (currently at 180 bed Hospital moving towards becoming a Level 3).  So I know protocols used in various places and situations, but am struggling with a couple of things here (I think it is difficult to be "between" being a trauma center, and not being a trauma center).  Here are the current issues I could use your feedback on (and what your practices are):

1.  I am told that in the State of Calif. (which I no longer live in), the Law is that only a Physician, P.A. or N.P. can place electronic orders for emergency protocol products.  I don't know if there is any such law in my state.  But one of the problems we have is that up until yesterday, the Physician taking care of the patient (i.e. in ER or OR) was the one expected to place the electronic order (though a Nurse could call with the verbal order).  This means we end up waiting a long time for the order so we cannot enter testing results and/or print subsequent "uncrossmatched" Transfusion Forms with patient information on them.  So in an ER meeting yesterday, we discussed having another Physician, a P.A. or a Nurse enter Emergent or Massive Protocol on behalf of the Physician.  Do any of you have Nurses placing these orders in the computer?  Both names would then be displayed in our particular system.

2.  So we have 2 emergency protocols.....Emergent (4 uncrossmatched RBCs) and Massive (4+4+1).  With both protocols, we do not honor any special requirements the patient may have (i.e. Irradiated; CMV-; etc. which I believe is the standard-of-practice).  Emergent Protocol is always/ only uncrossmatched RBCs.  However, we have said Massive Protocol could be Uncrossmatched or Crossmatched (if a patient is bleeding for awhile, we may have completed their testing and as we all know, Physicians prefer crossmatched RBCs.....but they still may need the type/ numbers of products that constitute Massive so they would then be receiving Crossmatched Massive Protocol).  Problem is.....for Crossmatched RBCs, our computer system actually performs a patient history search and forces Irradiated Products when appropriate (and a Physician can add a Health issue to request Irradiated if desired), but it does not perform this search for Emergent or Massive Protocol (automatically defaults to Leukoreduced).  And while we would give Leukoreduced to any patient needing Uncrossmatched Massive Protocol....if we follow our Crossmatched protocol, we should be honoring any special requirements the patient has (i.e. Irradiated).  But 2 problems with that now:

     a.  Would be difficult to keep up with Irradiating Units on a patient on Massive Protocol

     b.  Because our computer system does not do the Irradiation Search for Emergent or Massive Protocol (and cannot differentiate Crossmatched massive from Uncrossmatched massive)...unless a patient already had certain restrictions, we would not know then if this patient should receive Irradiated products (in our Hospital....and these days with the use of Hospitalists.....it is more difficult for them to have the knowledge of what patients should receive Irradiated products; that is why we built our system to search by pre-programmed diagnosis and/or a location of Cancer Center....so cannot depend on a Physician ordering Crossmtached     Massive Protocol to necessarily tell us that this patient should have Irradiated products.  Just wondering, do you guys only give Uncrossmatched Massive Protocol....or are there others that also offer Crossmatched Massive Protocol?  And if you give Crossmatched, do you honor special blood requirements?

Thanks in advance for your help.....

Brenda Hutson, MT(ASCP)SBB

[SMILLER]

I would say that we honor special blood protocols during a MTP like irradiation if possible. However, we would be detecting a previous requirement like that on only or BB system.  If they got an alert here it would most likely be from the BB, not from the hospital system.

I am pretty sure during a MTP that the physicians in charge are more worried about the immediate acute situation with the patient than whether or not they are likely to develop graft-vs-host from units of unirradiated leuko-reduced products.  Maybe something to discuss with your trauma team docs?

 

Scott

[BankerGirl]

We would not honor the special blood protocols because we couldn't honor them.  We don't irradiate blood and have very limitted (if any) supply of irradiated units.  I don't know what BB IS system you use, but our Meditech has an emergency issue function that basically allows us to give anything to anyone.  It will still pop up alarms if incompatible blood is issued, but it will allow it.  This can be done with crossmatched blood as well as uncrossmatched.

[Brenda K Hutson]

On ‎6‎/‎28‎/‎2016 at 11:01 AM, SMILLER said:

I would say that we honor special blood protocols during a MTP like irradiation if possible. However, we would be detecting a previous requirement like that on only or BB system.  If they got an alert here it would most likely be from the BB, not from the hospital system.

I am pretty sure during a MTP that the physicians in charge are more worried about the immediate acute situation with the patient than whether or not they are likely to develop graft-vs-host from units of unirradiated leuko-reduced products.  Maybe something to discuss with your trauma team docs?

 

Scott

Might have to let the Trauma Team docs and Oncology docs battle that one out......and we wouldn't honor it if still in the uncrossmatched mode....just not sure that once we are on crossmatch protocol, we can justify as easily, not honoring special requirements? 

Thanks

Brenda

[Brenda K Hutson]

23 hours ago, BankerGirl said:

We would not honor the special blood protocols because we couldn't honor them.  We don't irradiate blood and have very limitted (if any) supply of irradiated units.  I don't know what BB IS system you use, but our Meditech has an emergency issue function that basically allows us to give anything to anyone.  It will still pop up alarms if incompatible blood is issued, but it will allow it.  This can be done with crossmatched blood as well as uncrossmatched.

Right, we can override it from an LIS perspective.  I am more concerned about the question of what you can get away with once you have switched to crossmatch protocol.  I think at the very least, we will have to have a means of getting a waiver if we simply cannot keep up with irradiation.  Guess I need to run it by Trauma, Oncology and Pathology docs.

Thanks

Brenda

[Likewine99]

I had a trauma surgeon tell me one time that in a true MTP situation that they want us to give them whatever ABO compatible products we can give them as fast as we possibly can.

He mentioned that in a traumatic situation the body's immune response system shuts down because the body is sending all of its defenses to help it make itself through the trauma situation.

If the patient survives the MTP episode then it might be time to worry about antibodies, irradiation, etc.  And he also mentioned that the blood is passing through so quickly that he doubted very seriously if the patient would even have time to respond to foreign antigens.  

 

 

[Brenda K Hutson]

23 hours ago, Likewine99 said:

I had a trauma surgeon tell me one time that in a true MTP situation that they want us to give them whatever ABO compatible products we can give them as fast as we possibly can.

He mentioned that in a traumatic situation the body's immune response system shuts down because the body is sending all of its defenses to help it make itself through the trauma situation.

If the patient survives the MTP episode then it might be time to worry about antibodies, irradiation, etc.  And he also mentioned that the blood is passing through so quickly that he doubted very seriously if the patient would even have time to respond to foreign antigens.  

 

 

I know the Immune System protection works where antibodies are concerned during massive transfusion.....just not sure when it comes to Graft vs. Host Disease?  I will have to try and read up on that.

Thanks

Brenda

[Malcolm Needs ☆]

11 hours ago, Brenda Hutson said:

I know the Immune System protection works where antibodies are concerned during massive transfusion.....just not sure when it comes to Graft vs. Host Disease?  I will have to try and read up on that.

Thanks

Brenda

BCSH_TTF_addendum_irradiation_guidelines_final_6_11_12.pdfBCSH_TTF_addendum_irradiation_guidelines_final_6_11_12.pdf

 

I don't know if this would help Brenda, but it is a UK, rather than a USA Guideline.

[Brenda K Hutson]

On ‎7‎/‎2‎/‎2016 at 4:35 AM, Malcolm Needs said:

BCSH_TTF_addendum_irradiation_guidelines_final_6_11_12.pdfBCSH_TTF_addendum_irradiation_guidelines_final_6_11_12.pdf

 

I don't know if this would help Brenda, but it is a UK, rather than a USA Guideline.

Thank you Malcolm; that does help.  So it brings up that gray area I am struggling with.....in an emergency.  It is true that Massive Protocol is always an emergent situation, but my struggle has to do with the fact that if you have the time to switch from uncrossmatched to crossmatched (still Massive       Protocol), is the assumption then that you also have time to meet special requirements (we do not use electronic crossmatch yet....so there is a little time involved)?  I am leaning towards writing in my SOP that "if time allows," we will Irradiate units for patients on crossmatched MTP who require Irradiated; but that if time does not allow, to obtain a variance from the Medical Director.  I will run that by the Head of Oncology and Trauma Docs to make sure they are ok with that. 

My concern here (and it may just be a lack of understanding on my part) is that while I understand the theory behind the decreased risk of antibody      formation say in giving Rh POS to Rh NEG (etc.), I am thinking that the issue with Irradiation is the opposite....that the reason we give Irradiated is        because the patient already has a weakened Immune System and yet Irradiated products are still required to prevent the risk of GVHD.  So in my mind, I would think this would put them at a greater risk of GVHD (giving non-Irradiated to a patient massively bleeding) if we are only considering the Immune System status of the patient (i.e. since the problem in GVHD is the cells you are transfusing attacking the patient.....which I am sure you know), but      perhaps the excessive bleeding, also does not give the transfused cells a chance to mount an immune response against the patient??  That is the part I have never really thought about.

In getting feedback from some other Hospitals, there are some that do state that once they are on crossmatched massive protocol, they give Irradiated Products (if required) and only get a variance if they cannot keep up with the need.  Obviously, if the choice comes down to a patient bleeding to death vs. giving Irradiated products, we would opt to give non-Irradiated products (at least I have that part clear in my head ).

Thanks again........

Brenda Hutson

[Malcolm Needs ☆]

I can understand your reasoning Brenda, and can quite see your point, but I think that the fact that your units of blood will have been "on the shelf" for a while, the chances of there being sufficient viable T lymphocytes in them, and for these to remain in the patient's circulation long enough to cause TA-GvHD is unlikely - not impossible, but unlikely.

[Brenda K Hutson]

23 hours ago, Malcolm Needs said:

I can understand your reasoning Brenda, and can quite see your point, but I think that the fact that your units of blood will have been "on the shelf" for a while, the chances of there being sufficient viable T lymphocytes in them, and for these to remain in the patient's circulation long enough to cause TA-GvHD is unlikely - not impossible, but unlikely.

Good point....and that is what I was looking for....an explanation as to why you don't have to worry "as much" about Irradiation in a massively bleeding patient.

Thanks

Brenda

[David Saikin]

On ‎7‎/‎1‎/‎2016 at 1:33 PM, Brenda Hutson said:

I know the Immune System protection works where antibodies are concerned during massive transfusion.....just not sure when it comes to Graft vs. Host Disease?  I will have to try and read up on that.

Thanks

Brenda

I have to kind of disagree with you on this Brenda.  The immune system does work, however all the protective abs, including ABO isoagglutinins, are usually so diluted that they are ineffectual.  Case in point - we rec'd a transfer where the patient had rec'd 16 u B+ rbc and 20 B plasmas at the transferring institution.  We got him, he was B+.  4 days later they wanted to give him some more rbcs.  He was still B+ but his AB and D typings were mixed field - he was really an O Neg.  His bili went from 2 to 31 in 16 hrs and he hemolyzed to death.   I don't think you can say his immune system was working at the time of his immediate event.  It did come on strong after it recovered . . .

[Brenda K Hutson]

On ‎7‎/‎4‎/‎2016 at 1:22 PM, David Saikin said:

I have to kind of disagree with you on this Brenda.  The immune system does work, however all the protective abs, including ABO isoagglutinins, are usually so diluted that they are ineffectual.  Case in point - we rec'd a transfer where the patient had rec'd 16 u B+ rbc and 20 B plasmas at the transferring institution.  We got him, he was B+.  4 days later they wanted to give him some more rbcs.  He was still B+ but his AB and D typings were mixed field - he was really an O Neg.  His bili went from 2 to 31 in 16 hrs and he hemolyzed to death.   I don't think you can say his immune system was working at the time of his immediate event.  It did come on strong after it recovered . . .

Not saying (or meaning) Immune System doesn't work (just that it is weakened in this patient population), but rather that blood not in patient long enough for patient's immune system to detect the incompatibility of say, Rh POS cells being given to an Rh NEG patient (so I am more referencing a patient making new antibodies than discussing pre-existing  antibodies).  And I get your comment about  the dilutional effect of pre-existing antibodies (though wow, kind of surprised they got away with all of that for even 16 hours!!).  However, that patient population (the ones that require Irradiated products) does have a weakened immune system which is less likely to be able to protect them from Graft-vs-Host Disease (and the reason they receive Irradiated products).  That is why I was still thinking they could be at risk if not receiving Irradiated Products (same "reason" they need Irradiated Products in first place), unless somehow the massive bleeding is also keeping the transfused cells from mounting a  response against patient (and that is the part I am trying to learn about).    Does dilutional affect keep transfused white cells from being present "in numbers" enough to mount an immune response against patient?  I am thinking maybe not      because a lot of places do "try" to give Irradiated even to massively bleeding patient, but at some point, if you have to choose between patient bleeding to death and taking the time to Irradiate, you would choose to give non-Irradiated.

But just wondering David, am I missing something you are saying (or seeing in my response)?    I think I am getting more confused....

Thanks

Brenda Hutson

[AMcCord]

To answer you first question - nurses put in our LIS orders for Mass Transfusion protocol. There is a verbal from the ER doc or surgeon and the nurse in charge of running the protocol puts in the orders.

As to the irradiated products - that would be detected from Blood Bank records most likely. We don't have sufficient stock as a rule to run with irradiated products for very long, so would notify the on call pathologist immediately - he/she would then address that issue with the attending/surgeon/ER doc. You can't fix dead, so we would give non-irradiated blood in actual practice and document that the patient's physician had been notified. Whether or not we ordered an emergency shipment of irradiated product from our blood supplier would depend on the situation. I think addressing the issue in the SOP by stating that special needs would be met at the discretion of the pathologist would suffice.

[goodchild]

Question for the group: How often are hemorrhage/massive transfusion protocols initiated that don't end up being real massive transfusion protocols?  e.g. you prepare/issue a lot of blood but in the end only a couple of units are transfused because they stop the bleeding or re-evaluate the patient or whatever else.

[Malcolm Needs ☆]

I can't say, because I have not worked in a hospital for 16 years now, BUT, when I did, I was involved with three IRA bombs in London (Chelsea Barracks, Hyde Park Corner and Harrods) and two rail crashes (Paddington and Selhurst), amongst other things, and, in every case, without fail, the number of victims was over-estimated, and the amount of blood required was grossly over-estimated (by those in A and E) and, as a consequence, the Blood Bank was left with a glut of blood after the event, most of which expired.

[AMcCord]

23 hours ago, goodchild said:

Question for the group: How often are hemorrhage/massive transfusion protocols initiated that don't end up being real massive transfusion protocols?  e.g. you prepare/issue a lot of blood but in the end only a couple of units are transfused because they stop the bleeding or re-evaluate the patient or whatever else.

More often than not, but I like to operate by the Boy Scout motto - Always Be Prepared! The extra work is the cost of doing business. Sometimes it pays off big time, sometimes it doesn't.

[Malcolm Needs ☆]

17 minutes ago, AMcCord said:

More often than not, but I like to operate by the Boy Scout motto - Always Be Prepared! The extra work is the cost of doing business. Sometimes it pays off big time, sometimes it doesn't.

True, and in most cases I wouldn't argue, but there are times when it does not (big time), like the number of units of blood that expired after too many donors were bled on the day of, and the days soon after the Twin Towers atrocity.  They should have taken these people's details, sent most of them home and asked them to come back at a later date.  The waste went worldwide and did nobody in our profession any good.

[macarton]

We normally do not keep irradiated units on the shelf. Our blood center is an hour away.  Our LIS will warn, but will allow for issue.  We would inform the physician and issue per emergency protocol per their orders and request units   irradiated from our supplier.

[goodchild]

25 minutes ago, AMcCord said:

More often than not, but I like to operate by the Boy Scout motto - Always Be Prepared! The extra work is the cost of doing business. Sometimes it pays off big time, sometimes it doesn't.

Yes. I wholeheartedly agree.

The only reason I pose this question is because anytime we (bloodbank talk community) discuss the circumstances surrounding a massive hemorrhage protocol, true massive transfusion scenarios are the only topic. I believe the reality is that for non-trauma hospitals, the "false alarms" (or call them what you will) outnumber the true massive transfusion events.

Just last week we had a protocol called on a patient whose antibody screen was almost complete, with history of negative screens and numerous transfusions. Naturally, the screen was positive. We had issued a total of 3 batches in our protocol and it turned out they were actually able to stop the bleeding relatively quickly and transfuse conservatively (total of three RBCs, and serendipitously, all correspondingly antigen-negative).

[mollyredone]

Goodchild,

That is our issue also.  They call many more MTP than turn out to be.  One of our last ones had all the units returned to us...out of temperature of course.  Throw away four O Neg PRBCs and 2 liquid plasma.  Another MTP on a fellow with a 1.9 hemoglobin...they used 1 PRBC and one FFP.  Or they will call an MTP, get the first pack and then want 4 more FFP-is this the massive protocol or ordering a la carte?  Sorry to grumble.

[AMcCord]

On 7/7/2016 at 11:48 AM, Malcolm Needs said:

True, and in most cases I wouldn't argue, but there are times when it does not (big time), like the number of units of blood that expired after too many donors were bled on the day of, and the days soon after the Twin Towers atrocity.  They should have taken these people's details, sent most of them home and asked them to come back at a later date.  The waste went worldwide and did nobody in our profession any good.

From a transfusion service perspective - I have no problem with doing some extra work in the interests of the patient. But, I totally agree from a donor center view of things. I suspect there were thousands of units drawn after the Orlando club shooting incident that will end up outdated. I hope I'm wrong.

[Malcolm Needs ☆]

2 minutes ago, AMcCord said:

From a transfusion service perspective - I have no problem with doing some extra work in the interests of the patient. But, I totally agree from a donor center view of things. I suspect there were thousands of units drawn after the Orlando club shooting incident that will end up outdated. I hope I'm wrong.

Yes, I totally agree with your sentiments about patients.

[AMcCord]

2 hours ago, mollyredone said:

Goodchild,

That is our issue also.  They call many more MTP than turn out to be.  One of our last ones had all the units returned to us...out of temperature of course.  Throw away four O Neg PRBCs and 2 liquid plasma.  Another MTP on a fellow with a 1.9 hemoglobin...they used 1 PRBC and one FFP.  Or they will call an MTP, get the first pack and then want 4 more FFP-is this the massive protocol or ordering a la carte?  Sorry to grumble.

 In some patient events its hard to know going into a situation how its going to play out. Some waste is inevitable, but keeping it to a minimum is vital. It really pains me to have to toss O negative red cells and AB plasma.

We are currently engaged in a lengthy project/process to try to fix those kinds of problems - and others. We have a new poster of a process map for Emergency Release and Mass Transfusion for the patient care areas plus a similar version that allows the entry of information for use at the bedside. We are educating everyone. Lab is focusing on faster/more efficient. Nursing is focusing on what they are actually supposed to do, communication (don't bug the lab with multiple phone calls from multiple people about the same things!) and what the lab is actually doing for the patient (and how long it takes). The physicians are being educated on the fact that there actually is a protocol (seems to be a surprise to many of them) and how it works, plus education of what products might be used and when. We have pushed ourselves into the debrief sessions following the mass transfusion/emergency release events - it had apparently never occurred to nursing that we might have something to contribute or problems that they need to help us fix. We are working on notification - when does lab need to know something is going on so we can prepare for the possibility of mass transfusion, how should they notify us, and what phrases should they use for activation so that we are all on the same page.

Lab turnaround time has improved dramatically. and we are starting to see some promising results from nursing. We are planning cross-disciplinary table top drills, then live drills for later in the year to see how things are going. We are cautiously optimistic.

[goodchild]

25 minutes ago, AMcCord said:

 In some patient events its hard to know going into a situation how its going to play out.

I'm not trying to play armchair quarterback. I was only adding a light shade of gray regarding patients with special transfusion requirements.