Brenda K Hutson

Thanks, that was very helpful. My concern with the scenario of someone saying the specimen had been drawn 5 mins apart is that I would not think I would want the same phlebotomist to draw the patient twice (i.e. stand in their room for a few minutes; then stick them again). Kind of defeats the purpose of catching episodes where an incorrect patient is drawn (Yes, let's draw the wrong patient twice, shall we??). But I will have to check with my phlebotomy dept. Not sure they have more than 1 phlebotomist on the graveyard shift. Brenda

I know there was another Thread regarding a 2nd blood draw; but it does not provide all of what I am asking for. We are definitely moving in that direction. One place I previously worked did follow this protocol, but I rarely worked on the bench there (and when I did, it was in Reference) so I do not recall all of their protocol (though I am going to call them to collect more information). What I am wondering from those of you out there who perform a 2nd blood draw on patients w/o a history: 1. For Inpatients (but not in OR): What is your process for the 1st and 2nd draws (who does them; how far apart; are patients resisting; how much has this increased the workload for both phlebotomy, and your Transfusion Service staff)? 2. For OR: Same questions as above. This one I do recall from where I previously worked (but the process seemed tedious to me). The 2nd specimen was brought to the T.S. by a Courier when they wanted to pick up blood for surgery; the courier waited while the T.S. performed a quick blood type; then the blood was released. 3. Outpatients; do you obtain the 2nd specimen from them when they come for their transfusions (similar to OR; have a Courier bring a 2nd specimen; perform a quick blood type; release blood to Courier)? 4. Since the only testing performed on the 2nd specimen is a blood type; for those of you who log your specimens into the computer (which then assigns an expiration), how do you indicate that the specimen has not had an Antibody Screen so can not be used for subsequent crossmatches? I know our computer system would not allow a crossmatch on a patient specimen without a Type and Screen having been performed on that specimen? Brenda Hutson, CLS(ASCP)SBB

Couple of thoughts... 1. I recall at 1 Institution I worked at that we had a patient that kept hemolyzing when transfused. We could NEVER isolate an antibody in the serum (and DAT was Negative). We finally just gave them Jka Negative blood (cannot recall now if we have a non-transfused specimen and performed Kidd typings, or just "took a shot at it?" We certainly see anti-Jka much more frequently than Jkb. The patient stopped hemolyzing when transfused with Jka- RBCs. 2. At another Institution I worked at, we had a patient come into the ER with the clinical picture you described. In that case, the patient had not been recently transfused; but of course there was always the possibility of warm autoimmune hemolytic anemia. But a Warm Auto was not demonstrable. Never did figure that patient out. They were out at sea fishing one day; and in the ER hemolyzing the next. Don't know your patient's history, but you may need to "think outside of the box" on this one. If you have a pre-transfusion specimen, one thought is to perform Jka and Jkb antigen typing. Brenda Hutson, CLS(ASCP)SBB

I have seen partial D patients make anti-D but they were primarily patients who typed as Rh Positive; then appeared to make Ant-D (so wondered if Auto-D or Anti-D due to partial type; but had partial D confirmed). But I think the possibility would be there for a Weak D reacting only at AHG, to make anti-D (though rare). The decision about which types qualify for Rhogam, is an Institutional decision. I have seen different protocols. Where I am currently, we do not perform Weak D testing on pregnant women; only on babies. That is because we would give Rhogam even if they were Weak D positive; so why bother to find out if they are (though that sometimes comes back to bite you in that you get a strongly positive Fetal Screen Test on Weak D women). But in Institutions that prefer to "play the odds," they might say only Rh Negative women qualify for Rhogam; not Weak D (as you mentioned in your posting). Brenda Hutson, CLS(ASCP)SBB

Well, at a former large Medical Center I worked at (which stored coolers and freeze bottles in the OR), we would Issue and then tube (pneumatic tube) units to the OR with Safe-T-Vue Temp. monitors on them (keeping in mind that the tube does not always leave it's destination the second you key in the code). So I think that one key element is ensuring they are cool enough when they leave your dept. But then I don't know how far your Transfusion Service is from the OR. But it "could" be a solution (if you find the monitors change prior to even reaching the OR) to have transport take them up in coolers; then bring the cooler right back (though that is a lot for transportation; or if your supply of coolers is large, they could bring them back when coming to the Blood Bank). The first place I worked was another very large Medical Center. There were 3 OR suites (each consisting of many rooms) on 3 different floors; right above each other. There were large monitored refrigerators in each suite. With 27 years and 6 Institutions now behind me, I personally would not recommend this practice (and I would be surprised if they still do it); but what they did is this. Every morning, a Lab Assistant would pack up all of the units for all 3 suites for all surgeries in which there was blood crossmatched. She would layer them by suite, and take the OR schedule with her. She then knocked on the door of each suite; at which time one of the Nurses would come and perform a read-back with her of "how many units; for which patients" and check them off the list. The Nurse would then put ALL of the units for that suite, for that day, in the large refrigerator. If needed during surgery, they just went to their refrigerator and pulled the units. To me, the risk of pulling the wrong patient (especially in an urgent situation; and this did happen once or twice in my 5 years there) is just too great. But I just really don't like the idea of refrigerators in the OR in any fashion (but that is just my bias). I would rather just Issue each patient; as needed; via a transporter (whether in a cooler or not). Brenda

You are correct; this is definitely not a "right or wrong" issue. But as I was driving to work this morning (funny how things come to mind at strange times), I started wondering; when you say you match for Rh and Kell systems, are you saying you do that in addition to Alloadsorptions; or are you saying you just give Rh and Kell matched blood. Period. If the former, just curious why match at all if you are going to perform adsorptions anyway (unless like Sickle Cell patients, you are just trying to prevent them from making the 2 most likely antigenic groups); and if the latter, why would you not be concerned about something else (besides Rh or Kell) hiding under the Warm Auto? "Inquiring Minds Want to Know!" Thanks, Brenda

Which part sounds pompous; what I said or what you said? Sorry if what I said in that I certainly did not mean anything like that....and if what you said; I did not take it that way. You are correct that if they were S-s- that would change things (but for me, it would probably change to performing periodic alloadorptions over partial matching). And as far as Fy(a-b-); while most will not make Anti-Fy3, it is not difficult to find units; at least in my broader geographic area. But other than exceptions like those you mentioned, I would still proceed as I have been; matching for the major blood group systems. It has served me well for awhile now. But that's ok Malcolm; you and I can just "agree to disagree" on this one Brenda

Right; but that is what I was trying to clarify. I said I would give completely phenotypically matched "in lieu of" subsequent work-ups. If you can get that baseline phenotype and perhaps just perform an initial adorption, then I would just continue to give phenotypically matched. An alloadsorption isn't going to catch a High Incidence in that transfused patient anyway. Which is not to say if I gave phenotypically matched but had reason to suspect perhaps there was a High underneath, I might to retic separation and type with some frozen serum negative for various Highs, and/or run patient's serum against a High Negative Panel of cells. I used to be a "purist" as Phyllis Walker likes to call me (continue to do adsorptions rather than give phentoypically matched blood), but I have come to see how much easier her ways are (unless of course you were to get a patient with a difficult phenotype to match). Brenda Hutson

Well, sounds like I am going to be the "ultra-conservative" one here, however..... If I am going to give phenotypically matched units in lieu of subsequent work-ups (and I am assuming that is what you mean; that you would not be performing subsequent adsorptions , I give complete phenotypically matched (i.e. Rh, K, Duffy, Kidd, Ss). And as Malcom said, matched does not have to mean exact (i.e. if patient is S+, the unit my be S-; but doesn't matter; etc). I guess my thought process is this: even though Rh and Kell systems may be most antigenic, that does not mean they will not make any of the others (and this is different than providing Rh and Kell system compatible blood for sickel cell patients until they actually make an antibody; they will continue to have an antibody screen performed each time and once they do make an antibody, they will receive complete matched; with the warm auto, if everything is coming up positive, you do not know what might be lurking underneath). What am I missing? Brenda Hutson, CLS(ASCP)SBB

Not sure if your question is directed to me, or to Kathy? Brenda

A few thoughts come to mind as I read your response: 1. I don't view it as the temp. monitors being problematic because they came back red (since your thermometer confirmed that), but rather that it may give more validity to the FDA's move in the direction of taking the temperatures instead of assigning some arbitrary time (most places use 30 mins) in which to return the unit. 2. When I validate new coolers, I place temp. monitors on them as well as use a thermometer. I have not noticed discrepancies between the monitor turning red and the actual temperature per the thermometer. 3. I am "assuming" you placed the units in a cooler (your response does not state that but usually one does not put temp. monitors on unless they are going into a cooler. So I am thinking that one of two things occurred; either the OR had the units out of the cooler for an extended period of time (and as I have said before, you would be shocked by some of the things I have come to learn occur in operating rooms); or, perhaps the units were crossmatched just prior to being placed in the cooler, and warmed up at room temp. I have seen that in the past and have seen that sometimes, the monitor may not turn red immeidately upon placing it on these "warmed units," but by the time it reaches the OR, it has. For that reason, when my staff are either crossmatching units that are going to immeidately be Issued to a cooler, and/or, are Issuing units to be placed in a cooler, I have told them to place the units on coolant packs. This seems to work really well. Brenda Hutson, CLS(ASCP)SBB

Well, we are talking about 2 different scenarios (in my mind and experience) You are talking about taking the temperature on units returned after Issue (i.e. Issued to a Nursing unit). We are also going to start doing that as soon as we get the IR thermometer validated. The temp. monitors are only used for units going into coolers. If you use coolers, I personally would NOT recommend that you just take the temperature of the units when they are returned in the cooler. Why? Glad you asked! Because you have NO IDEA what happened to those units once they left you; and I can tell you, I have heard of a lot of scary things that have occurred in the OR (from 6 different Institutions). When you use these irreversible temperature monitors, you know if they ever took the unit out for too long. To take the temp. when it comes back in a cooler just means it was "back" in the cooler long enough to get back into temp. When I started at my current Hospital 3+ years ago for example; if units were Issued in a cooler but say someone forgot to put temp. monitors on them; they would "feel" the unit and if it felt cold, they would accept it back. BAD IDEA (for reasons above). Just my thoughts on the subject... Brenda

Those are not the temperature monitors we use. We use the Safe-T-Vu monitors. I have used the flower (HemoTemp) monitors and I personally do not like them (i.e. for reasons you mention). The key to the Safe-T-Vue monitors is making sure your units are cold enough "while applying the monitors." When we take units out to Issue for a cooler, we place them on coolant packs so they stay cool; otherwise, we can have trouble with monitors turning red before they even leave our dept. This is also an important step when you are crossmatching units for a STAT (which will go in a cooler). I have seen instances where the units were out for a short time while the Tech. pulled segments, etc., causing problems with the monitors then. There was an old type which I really liked (as far as what was the most stable) except that they were glass (BAD idea for bags of blood). I have not seen those in many years and my guess is they are no longer around. Brenda

I suspect the primary issue is one of technique. It is critical that each step be followed precisely; especially the temperature of the saline (and my guess is, this is where most of the problems lie). I think that if not followed strictly, just about anyone could prewarm away about anything! Certainly the stronger the antibody is, the more difficult it would be; but of course a weak antibody can be every bit as deadly as a strong one (especially if missed and an anamestic response is mounted). I have seen Jka antibodies prewarmed away; even by seemingly "competent" Techs. I am just very wary of prewarming unless performed by people with a lot of experience. But that is my bias.... Brenda

Good to hear; thanks Brenda

Ok, well I have to tell some of my stories now. Both of these were from clients when I was a Reference Lab Supervisor. 1. 1 Hospital sent us (within weeks of each other) 2 hemolytic transfusion reaction work-ups; 1 patient with anti-c and 1 with anti-E and anti-c. And they were hemolytic; you could not see where the cells stopped and the plasma started. The thing is, both patient had positive antibody screens pre-transfusion. And both patients had a panel performed. And on the panels, in both cases, the antibodies were strong (2+) and clear cut. So why the hemolytic reactions? They had a Policy that when they got an antibody, they always tried to prewarm it; if it went away, it "was nothing;" if it didn't, then they had to identify it and provide antigen negative blood!! And as scary as that Policy was, I don't think they even noticed the "beautiful; perfect" specificity on their panels! We should all have such nice panels to identify! After the 2nd reaction, I called their Medical Director and strongly suggested that they "cease and desist" with that Policy; and that furthermore, I felt that they should immediately send all positive Antibody Screens to our Reference Lab for work-ups in that I personally (if I were that Medical Director) would not sleep at night knowing they were doing work-ups. The Medical Director followed my instructions. 2. I used to put on seminars twice a year; all day; 6 speakers. The last hour I often had myself and the 2 managers of the other local reference labs in the area do an "Ask the Experts." Something that always came up (which I have very strong feelings about) is the issue of prewarming. We would even try to scare them, telling them the stories of Jka or Vel that were prewarmed away (but then more Techs. than I would like to think, also think V is Vel; so what can I say). It was not even a week later that we received a work-up from one of our Hospitals in which they had almost successfully prewarmed away an anti-Vel! Fortunately they failed; but too frequently, prewarming in the hands of many Blood Bankers is a huge risk!! Brenda Hutson

Right, but as I mentioned before, I have seen an anti-f identified as many things (including Jka at 2 different Facilities)! If I knew it would always be misidentified as an anti-c, I would not be as concerned; but I know from experience that this absolutely is not the case. When people are inexperienced in antibody identification, they often look for a pattern rather than going through the steps of ruling out first; seeing what is left; and working from there. And on any given panel, who knows which Antigen will be present on most of the f+ cells (besides c). In an ideal world, such people would not be working in the Transfusion Service, but if you find a way to accomplish that, let me know! Brenda

Did you mean to say anti-C; or anti-c? You may very well have been discussing C; just clarifying since there was much discussion about f and the relationship to c. Brenda

And from my years as a Reference Lab Supervisor, I could bring up horror stories much worse than any of these concerns. It actually made me create a list in my mind of Hospitals I would never want to be a patient at! I am shocked at the lack of knowledge of some of the Techs. who are working in Transfusion Services; even some who are the supervisors!! Brenda

So you never have the scenario, where say you are running low on the current lot # of GEL cards; so you want to QC the new number to ensure there are enough to last 24 hours? And if you do that, you certainly do not need to repeat the QC on all of the other reagents; you can just repeat the Antibody Screen and GEL by clicking on TEST instead of TEST ALL. Anyway, we do it from time to time if we have enough of a given reagent that we don't want to just toss it; but we may not have enough for 24 hours until we repeat the QC. But perhaps you perform QC each shift?? Brenda

Right; but when coolers are taken places and "dropped off" by couriers, you could potentially end up with several coolers in a general outpatient location area (i.e. an outpatient Oncology Center we send coolers to). It is just 1 more alert that hopefully catches the eye of the transfusionist. Is it necessary? Who knows. What is necessary in any given Institution may vary based on SOPs; protocols; workflow; staff experience (both within the Lab and outside); etc. etc. Everyone has their own comfort level; and that can certainly vary from Institution to Institution (I know it has for me). But with this issue at my current Institution, it is not due to a lack of comfort, but rather was the protocol when I arrived and I have not felt the need to change it. Brenda

Well, it is true that some panels only have 1 cell that is c+f- (i.e. Ortho A); but if you look at Ortho B and probably some Immucor Panels, there can be several cells that are c+f-. That is when I become concerned that the inexperienced Tech. will not necessarily think that anti-c is "the closest thing." And yes, I just noticed last week when looking at some Immucor Panels that they had removed f. I understand their point; that it is an assumption on their part. But it has always been that way and to remove it, in my mind, will become "out of sight; out of mind." Brenda

Tech. performed Daily Reagent QC yesterday (TEST ALL). Then wanted to QC a new Lot# of a Reagent but the entire screen went blank except for A,B. And as you know, it expires at 2359 the following night. So someone in I.S. extended the expiration and we performed it manually and documented it on a manual form; both yesterday and today. Rumor has it that it is working now. I.S. told me that their calls were not even being returned; then when they were, they were basically told that they (Mediware) had no idea what the problem was. Without that QC date being indated, you cannot perform testing (as I 'm sure you know). I am glad that could be manipulated (though that was also done by my staff, not from Mediware). We have been on the system since 2008 and I continue to hear complaints from the I.T. dept. about the support. I actually like the system from a bench perspective though. Very user-friendly for us. Brenda

They can cause reactions; even if not severe. I realize we can deduce, the same as Immucor has been, which cells are f+ (according to genotype); however, given that I have found the majority of Techs. don't even know what anti-f is, I am concerned this will only make that worse. And as I said, unfortunately, an anti-f is not always mis-identified as anti-c (in that you can have cells that are f-c+). If the reactions don't fit a perfect pattern, many will just "pick the closest thing" on the panel. Scary, I know; but that is what I have found to be true in my 27 years. Brenda

Just curious how many of you use HCLL (Mediware) in your Lab? Do you feel you get good support when you have problems? We have had a major problem since yesterday; poor service in even calling back, much less resolving the problem. Interested in other systems in-use that people are really happy with... Thanks, Brenda Hutson, CLS(ASCP)SBB