BSIPHERD

We would select an Rh Negative unit, do an AHG crossmatch, and test unit for Cw antigen.

You can request that you receive a lot that has Jk(a+b-) and Fy(a-b+) cells (there's generally a name for it, such as primary lot).

We occasionally see what appears to be Anti-M in an M positive person. When we see them we report an Anti-M with the following comment: Anti-M may occur in patients who are M positive. Most of these are autoantibodies, although some appear to be alloimmune in nature. If transfusion is necessary, compatibility may be determined by random crossmatching of appropriate units. 22% of donors would be expected to be M negative.

We do. I think you need to if you are CAP accredited. And regardless, I think it is good practice.

Is there any way you can share your procedure using the buffered gel cards? I'd really like to go that route. What did you do to validate the procedure and are there references available? Thanks for any help.

We also switched to Rhophylac. One of our reasons was patient satisfaction. I'm told by people who have received IM RhIG that it isn't a pleasant experience. If you can give it IV, it makes patients happy!

We have developed a third Rh type for these patients - It is *Negative*, so we have Rh Positive, Rh Negative, and Rh *Negative*. The codes we have in our LIS for these is POS for Positive, NEG for Negative, and DEP for *Negative*. DEP comes from Dependent, the Rh type depends... Who actually reports on the patient's chart is: *Negative* *Rh type is dependent on reagents used, tests performed, and/or technical performance. Patient may have been previously reported as Rh Positive or Rh Negative. For Transfusion Service testing, the patient will be treated as Rh Negative and will receive Rh Negative blood for transfusion and/or Rh Immune Globulin. As a Blood Donor, patient will be treated as Rh Positive.* Our blood tags just print the first 10 characters for Rh so the blood tag for Rh is *Negative*. We have QA set up so that red cells for DEP patient need to be Rh Negative, except for Autologous units.

When we realized (about a year ago) that some CAP inspectors were doing this, we realized that for tube polyspecific DAT we were going to have to do it twice if negative - one to add Complement Coated Cells to and one to add IgG coated cells to. So we decided to discontinue polyspecific DAT. When we have a DAT ordered now, we perform it with Anti-IgG and with Anti-C3.

I not aware of any instances of a weak D typing being a "carryover" from C. We would consider this patient a candidate for Rh Immune Globulin. r'r is an unusual phenotype, but not really all that rare.

I used to have a friend in England who would make us fresh scones with clotted cream and strawberry jam - it was wonderful - and great memories. Have a great vacation.

Your original posting and the panels you posted led to a valuable and interesting discussion. So I guess you could still have posted that and say there were differing opinions in your lab and ask for others input. I sympathize with your problem and it makes me feel lucky that I work with a great team of people where there is open discussion of problems.

I believe an antibody only needs to be identified once. Once you have identified a clinically significant antibody, you are obliged to respect it from then on. If an Anti-Jk(a) is identified today, you will give Jk(a) negative blood from now on. So whether it is currently detectable has only one point of significance to me – can I use the serum/plasma to screen for compatible units or do I have to go straight to reagent typing serum. So we may run one cell just to see if it’s reacting. But Standards says you need to do antibody detection testing on every specimen collected for pretransfusion testing (and it has to be collected no more than 3 days prior to transfusion if the patient has been transfused or pregnant in the last 3 months). It also says that in patients with previously identified clinically significant antibodies, methods of testing shall be those that identify additional clinically significant antibodies. So to me that means you have to run selected cells that are positive for additional clinically significant antibodies the patient might form, but negative for the previously identified antibody/antibodies. Re-identification of antibodies already identified at your institution adds to health care cost and makes no difference in the way you treat the patient. Any way, that's my 2 cents worth!

We use Gel. When we have a positive screening cell, we perform a panel. If the panel is negative, we repeat the positive cell with PEG. If it is negative, we report "Confirmatory panel studies were required because of reactions in initial testing. Confirmatory testing was negative." We have had less of these types of reactions since we started keeping our 0.8% cells in black boxes that Ortho provided for us (they look like plastic recipe boxes - in fact we got one at a discount store that was a little bigger to keep a panel in).

Our wonderful Blood Blood pools our FFP for us. The code for pooled thawed FFP/CP2D is E5309 and the code of pooled thawed cryo reduced plasma/CP2D is E5305.

Malcolm, I love reading your stuff. Thanks for your input. I didn't mean I would never do a differential adsorption when there are negative cells, I just wouldn't go directly there as my next step in the situation given. I don't think there's enough evidence that there is an autoantibody there to make that the next step - and that's where I think it can be dangerous. Certainly differential adsorption can be used to separate antibodies if that's the purpose. Certainly technique can make a big difference on the amount of dilution that occurs, but the characteristics of the particular antibody can also make a difference on how it's reactivity is affected by the adsorption. Love these discussions!!

I think it's very dangerous to go directly to either auto or differential adsorption when there are negative cells on the panel. I didn't look at the panel really closely, but it seemed that all cells that were positive were C, K, and/or Fy(a) positive and the negative cells lacked all three. It might have needed a few more selected cells to "rule in" some of the antibodies (we like to have 3 cells positive and 3 cells negative - and you have the 3 cells negative - ideally we like to have 3 cells positive so we'd like 3 C+ cells that were Fy(a-) and K-, etc. - but we don't always reach that). And you have antigen typed the patient and the patient is negative for those antigens. Adsorbing plasma with cells causes a little dilution of the antibodies and changes things a bit so it's particularly dangerous to use when you've got clear cut antibodies to try to rule out those antibodies. We never go to warm or differenital adsorption unless we have also shown warm autoantibody in an eluate. We don't do an eluate everytime, but we do one before we call anything warm autoantibody. If I were on a jury and the patient had a bad outcome, I'd have to find for the patient.

When a unit is incompatible with neat plasma and no reaction is seen with auto or with differentially adsorbed plasma, we review it with a pathologist. If the pathologist okays transfusion, we call the crossmatch INCOMPATIBLE-OK'ed. We also add a comment to the order that says where nnnn is the pathologist's name. UNITS ARE INCOMPATIBLE. TRANSFUSION OF INCOMPATIBLE UNITS REQUIRES DIRECT CONSULTATION WITH A PATHOLOGIST. TRANSFUSION OK'ED BY DR. nnnnn. If differentially adsorbed plasma showed no alloantibodies, we also add a comment No underlying alloantibodies were detected when differentially adsorbed plasma was used. However, antibodies to high incidence antigens cannot be ruled out.

We stopped allowing hold tubes a few years ago for the following reasons. 1. At the AABB meeting several years ago, it was pointed out that having Hold Tubes for Blood Bank could lead to legal problems. If a hold tube was collected and not tested, then the patient had an emergent need for blood, it the patient had a serologic problem (or the tube was deficient - i.e. mislabelled, hemolyzed, wrong tube type, etc.), it could be claimed that we had the tube for long enough to resolve the problem and we did not. We stood a chance of being legally liable. 2. We had several instances where a patient went to surgery and patient care personnel assumed there was blood bank testing/components because there was a BB No. on the patient's armband. We did not, the BB No. was from a hold tube. 3. The amount of resources consumed was significant. We collected more Hold tubes than Type and Screens and/or Crossmatches. We also see a significant number of patients with Probably passive anti-D. If the patient has rec'd RhIG recently, we do a 1:8 dilution. If it's negative, we do a Modified Antibody Screen to rule out additional antibodies. We do not require a Type and Screen to be converted for probably Passive Anti-D and we allow I.S. crossmatches.

There is a method in the AABB Technical Manual (p. 897) to separate transfused red cells from autologous red cells in patients with hemoglobin S disease (uses hypotonic saline). Also, the little e antigen is pretty complex expecially in blacks. Sometimes what appears to be autoanti-e, particularly in sickle cell patients, turns out to be some form of alloanti-e. I know they've worked at lot with these at the Red Cross in Philadelphia. I can't really give you more information, but I know it's out there.

A few quick intial thoughts for you. 1) Are you doing a DAT on the donor. If the donor has a positive DAT, an AHG XM will be incompatible. 2) If the patient has Bg antibodies, a unit might be incompatible, but the panel may be negative. 3) If an ABO antibody is present (i.e. Anti-A1 in A2 patient), the unit may be incompatible and the panel negative. 4) The unit is P1 strong, the patient has a weak Anti-P1 and none of the panel cells are P1 strong. 5) The patient has an Anti-Sd(a) and the unit is Cad+, etc. Of course, an antibody to a low incidence antigen remains a possibility, but it's not the only one.

Here are our "alert values". The ET code column is just an English Text code that gets put in the computer to document. Tx Rx Alert Values No. Alert Value ET Code 1 Pink or red plasma. TXRX1 2 Any shade of red, brown, or black urine except when the urine microscopic shows intact red cells. TXRX2 3 Positive DAT on post-reaction specimen when pre-reaction DAT is negative. TXRX3 4 Patient in shock that may be due to anaphylactic reaction or transfusion related sepsis. TXRX4 5 Record check discrepancy involving patient or unit identification. TXRX5 6 Positive Gram's stain or culture on transfused unit. (Pathologist and patient care personnel will be notified by microbiology.) TXRX6 7 Signs and/or symptoms of TRALI. TXRX9 Other Alert Values No. Other Alert Values ET Code 8 Laboratory received notification from supplier of a positive bacterial detection test on a transfused unit. See RX8. TXRX7 9 Blood has been issued uncrossmatched and the completed crossmatch is incompatible. TXRX8 No. Other Alert Values 10 Compatible Red Cells cannot be obtained for a bleeding patient. If incompatible blood is to be transfused, initiate a “Medical Necessity for Deviation from Blood Bank Procedure Documentation Form”. Complete the first section, make a copy for the department, and send original to the pathologist. When the form is returned, complete the last section.

You said this had happened once in the past, before it happened at your location. It may be worth while to type out the donor. If it happens again, you could type out that donor and see if there is anything in common (i.e. both units K+ or both units ccDEE or both units Kp(a+). I think it would be worth while to also do AHG crossmatching for this patient in the future. Interesting patient, keep us updated if any further developments! Thanks.

WBIT is Wrong Blood in Tube.

This is from our Massive Transfusion Protocol procedure: 1.3 Patient criteria: Patients who show clinical evidence of exsanguinating hemorrhage require activation of the MTP. This may include category I trauma patients, aortic rupture, surgical misadventures, etc. Patients likely to require large volumes of fluid and blood should be considered for inclusion in this protocol as soon as one of the following is evident: No. Criteria 1 Hypotension: Patients with evidence of injury and systolic blood pressure (SBP) < 80 in an adult or < 60 in a child under the age of 12; or SBP from 80-90 that does not respond to a rapid infusion of 30 ml/kg of Lactated Ringers (2L for a 70 kg patient). 2 Major obvious blood loss: >700 mL immediately out through a chest tube, multiple long bone and/or pelvic fractures, heavily blood soaked clothing, etc. 3 3 units of Red Cells during resuscitation: and will obviously require additional transfusion.

Welcome Old Timer from a fellow Old Timer. I started in the early 60's and I'm still going. The lab was just changing over from glass bottles to plastic bags. One of my early memories is someone dropping a glass bottle of blood on a tile floor... Also, we had just started doing open heart surgeries. We drew 3 donors the morning of surgery - and one was drawn in heparin. I remember having a bottle of cough syrup sitting by a bottle of iodine (for drawing donors) - and being in a hurry and taking a swig of iodine rather than the cough surgery. I got halled off the the Emergency Room because I started vomitting brown stuff and everyone thought I was vomitting blood! We also smoked, ate, and played bridge in the blood bank. It's fun to go down memory lane - Thanks!