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Medical Director approval for Least Incompatible blood for transfusion


Candybar

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At work, we have had discussions as to whether CAP/AABB requires a pathologist's approval to transfuse least incompatible blood to our WAA patients. I was hoping some of you could give us insight. Some think it should be per specimen and some think it should be per transfuse order. Your thoughts please!

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Our pathologist (Blood Bank Medical Director) wants to approve each case of transfusing least incompatible units.  He will often speak with the ordering physician to discuss benefits vs. risks involved.  Once he has approved the transfusion of least incompatible for that patient, we do not need further approval unless something changes.  So far, in my career, these patients have never reacted to the transfused blood.  Usually, they were already hemolyzing their own blood and needed transfusion to correct very critically low H & H's.  

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I am sorry, but I must admit that I am surprised the term "least incompatible" is still being used some 14 years after the commentary in Transfusion written by Lawrie Petz (Petz LD.  "Least incompatible" units for transfusion in autoimmune hemolytic anemia: should we eliminate this meaningless term?  A commentary for clinicians and transfusion medicine professionals.  Transfusion 2003; 43 (11): 1503-1507, PMD: 14617306).

In such a position (particularly if it was at night, which it usually was!) we had catre blanche to give out the blood as "suitable" after cross-matching with adsorbed plasma, unless the adsorption didn't work (in which case we used to give ABO compatible, Rh- and K-matched blood - and kept our fingers crossed), when we would tell the Consultant on-duty what we had done to get rid of the auto-antibody, and they would telephone the referring hospital laboratory and tell them to do what we said - but they then took responsibility if anything went wrong (in theory - fortunately, nothing ever did, and so this was never tested)!

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We do use the term "least compatible" around the lab in these situations, and there may be a written order or comment somewhere for "transfuse least incompatible" from a physician, but they still have to sign a release.  Generally they do not have to consult with our pathologist here unless a red flag appears for some reason.  The blood set up is released as "incompatible" with a comment appropriate to the circumstances.

BTW, any opinion on how much difference it is going to make to the patient in these circumstances in transfusing, say,  a "1+" incompatible RBC compared to a "w+"?

Scott

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1 hour ago, SMILLER said:

BTW, any opinion on how much difference it is going to make to the patient in these circumstances in transfusing, say,  a "1+" incompatible RBC compared to a "w+"?

None whatsoever.

The usual specificities involved in such cases are anti-Rh17 or anti-Rh18, which mimic "normal" Rh antibodies, such as anti-E and anti-e, but, as everyone (within reason) expresses the Rh17 and Rh18 antigens, the source of the blood (the donor) makes no difference - and there is just not sufficient D--/D--, D../D.., D--/D.., Rhnull blood around to give these patients "real" compatible blood.

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I agree "least incompatible" is not an appropriate term to use.  We had stopped using it until we got a new computer shared with other facilities and the only way to issue these units in the computer was to interpret as Least Incompatible.  We kept the same paperwork for signatures stating "Incompatible", but had no choice in the computer.    Personally, I think interpreting as Least Incompatible gives a false sense of security. 

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11 hours ago, mcgouc said:

I agree "least incompatible" is not an appropriate term to use.  We had stopped using it until we got a new computer shared with other facilities and the only way to issue these units in the computer was to interpret as Least Incompatible.  We kept the same paperwork for signatures stating "Incompatible", but had no choice in the computer.    Personally, I think interpreting as Least Incompatible gives a false sense of security. 

I agree with you wholeheartedly that "least incompatible" gives a false sense of security.  It is also a meaningless term, rather like somebody being a "little bit pregnant" - no, you are either pregnant or you are not, and blood is either serologically compatible, or it is not.

What really annoys me though, and I am not getting at you personally here (although it may sound like I am, so I apologise in advance if it does), is when we allow a computer to dictate to us, rather than us dictating to the computer.  The computer should be there as our slave, and not the other way around.  Surely, if we want to say that a unit is "suitable" for a patient, rather than "least incompatible", we should be able to programme the computer to say so, rather than the computer "programming us", to say what "it wants"?

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On ‎9‎/‎17‎/‎2017 at 4:50 PM, Candybar said:

At work, we have had discussions as to whether CAP/AABB requires a pathologist's approval to transfuse least incompatible blood to our WAA patients. I was hoping some of you could give us insight. Some think it should be per specimen and some think it should be per transfuse order. Your thoughts please!

Regardless of the terminology used at the transfusion facility, did anyone ever discover what the CAP or AABB has to say about Lab Director involvement?

Scott

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We didn't have the medical director sign. The patient's physician signed.  The Medical Director was not always available and felt the patient's physician should be held responsible. Since the work-up takes a while, we started discussions and getting signatures on an " Incompatible Blood Release" form early so there wouldn't be an additional delay once we had appropriate blood. 

Just a few comments about sharing Blood Bank computers with other facilities.  I am now retired, but a couple of years before leaving , I added a section to my validation policy titled "post-implementation validation".  I wanted an assessor to see it and ask why I needed that section.   I wasted so much time and energy trying to explain to corporate and local management that all affected facilities needed input and knowledge of changes prior to the changes being placed in the live system.   

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There is no requirement to have medical director or physician sign off.  Any rules in place would be strictly internal policy.  But once it's policy for your facility, you have to follow it.  So it very much depends on the comfort of your pathologist/hematologist in charge.  If he/she is conservative, they will probably want to know.  if he/she is progressive, then not.  Either way, I'd think is should be in a policy/procedure spelled out for your staff. 

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