BB Gal

Giving O units (or A2) keeps our computer happier on patients with documented anti-A1.  Of course, that is the prime objective these days, right?  We bow to our computers!  

There is absolutely no reason to give group O red cells to a recipient who is A3.  Even if the patient does develop an anti-A1, unless that antibody is reactive at strictly 37oC, they can still receive A1 red cells, but, if the anti-A1 does react at 37oC, there is no reason not to transfuse with A2 red cells that are IAT compatible.
Personally, I have never seen loss of A or B antigens through ALL, but I have with AML.  In fact, in one case, we were able to follow whether the patient was in remission or relapse by the strength of the reaction of the A antigen with various anti-A reagents, but this was many years ago, and I honestly can't remember whether these were human-derived polyclonal reagents or early monoclonal reagents.

Thank you everyone for the replies! I definitely have a lot of reading to do.
@Bet'naSBB I definitely agree that the patients have to live to have a problem. I appreciate the info about your facility. I hope to read more research about the WB that's being done at hospitals like yours! I am also curious about studies going on that involve obstetrics and cardiac LTOWB MTPs.
@Neil Blumberg Thank you very much for the articles. I am also worried about the incompatible plasma in the regular red cells for sure. I feel like I'm in between a rock and a hard place.
Just to make sure I've understood, even if a patient just got their total plasma volume replaced with Group O albeit Low titer plasma, we should switch all products to their blood type the second we get a result? 
(I am also curious what you think of blood centers labeling red cells from antibody positive units as regular red cells and don't treat them as antibody positive units needing a minor crossmatch. The blood center claims that the Additive Solutions dilute the titer "enough." I admit I haven't looked for any research on this yet. I don't know if they titer the supernatant or what to prove this.
Maybe this also needs to be brought up in paradigm shifts alongside rethinking out of group ABO compatible red cell transfusions.)
@jshepherd Right now, I would like to limit it to 4 LTOWB and then switch to components until more research is done, but my hands are tied. No amount of articles or concerns has changed our Trauma department's mind. They want unlimited LTOWB in their perfect world, but we were able to limit it to 10 to match the "model" facility's protocol. Maybe a retroactive study can be done here at some point. To be clear, thankfully I have no evidence that any of our patients have experienced harm because of the LTOWB specifically. This is more of a proactive worry.
We are unfortunately not accredited by AABB, but CAP has a similar standard and I outlined our policy as no limit for LTOWB, but if more than 4 transfused, give Group O red cells. After getting Dr. Blumberg's insight, I may be editing it again!

Switch back to the patient's own ABO type as soon as possible is my advice.  For everything.  RBC, platelets, cryo, plasma.  Worrying about the anti-A and anti-B in low titer whole blood is relevant, but so is the smaller amount of incompatible plasma in group O red cells, which are not low titer. There are rare reports of severe hemolytic reactions to group O red cells in non-O patients. Furthermore, the patient is continually making their own group A, B or AB red cells, so hesitancy about transfusing their own ABO type is not helping things get better.  By giving additional group O products we are making the problem worse, not adding safety in any way.
Furthermore, the non-O patient's endothelial cells, platelets, von Willebrand factor, hepatocytes, etc. are all incompatible with the transfused group O plasma, and their function is impaired when modeled in vitro, and leads to increased bleeding. 
Thus there is no benefit whatever in giving group O red cells (or whole blood for that matter) to non-O patients once the hemorrhagic problem is largely under control. And there is likely added risk.   It is only adding harm and reducing the inventory of group O blood for group O recipients.  A total mistake of the last few decades in my opinion. Giving group O plasma containing products to non-Os is only reasonable when you don't know the patient's blood group, or don't have their blood group in stock, or it's an emergency with no time for giving type specific.
No one ever went broke overestimating the importance of the ABO blood group in transfusion.  See attached for the literature references.
ABO trauma commentary Frontiers bioengineering.pdf Reconsider ABO compatible:universal donor.pdf ABO ARC MAC copy.ppt

I'm with Dr. Blumberg, we cap our LTOWB for trauma MTP at 4 units. This is due to inventory as well as not wanting to give non-ABO identical as little as possible. We have had zero adverse events thus far. The more O you give a non-O patient, the harder it is to determine their true type as well, especially if you don't get a sample drawn ASAP. Switch to patient's ABO type as soon as you can, and only fall back to type O red cells if inventory is in trouble. 
Also agree with Bet'na - the patient has to live to have a problem, but we can mitigate the problems by capping how much potentially incompatible plasma we give. 
There is an AABB standard 5.27.2 that states that your SOPs must indicate the maximum volume/units allowed per event. You can define that yourself, there isn't really a guide as to how much is too much. There are facilities out there that have no limit and some that have a limit, as evidenced by the responses in this thread. Standard 5.15.4 applies to this as well, which states that you have to have a policy concerning transfusion of significant volumes of plasma containing incompatible ABO antibodies, ie type O plasma to non-O patients. 
I've been doing level 1 trauma for almost 20 years, and it can feel like the wild west, reach out if you need clarification or real-life examples of things. Happy to help.

We are a Level 1 adult and Peds trauma center.....we don't have a limit............
We will give any MTP patient O POS (leuko reduced) LTWB until our supply runs out.  We will give Oneg to peds - but if we run out of Oneg - they will get Opos.  Our facility is currently involved in several studies using WB in the trauma setting.
In the words of our Medical Director and manager..........."They have to live to have a problem"  Might sound crass to many - but, it's true.  For all the patient's we have transfused out of group WB to - we have had VERY FEW delayed reactions - maybe 2 anti-A's in the eluate and a few anti-D's - but all were males.
Our 1st concern is saving the patient.........

Our Blood Bank uses Hemotemp II's but they are only good applied to the bag for about 2 days. They also have to be activated with a 40C incubator. We use those for units in OR coolers and trauma.
If you want tracking for the life of the unit, Safe-T-Vue's are pretty much the only option.
I second everyone's frustration with the Timestrip BT10's. We tried them for our trauma bay and they fell off all the time despite prepping with alcohol and wiping condensation off the bag. They'd also activate if you looked at it wrong. Our rep said the lots we got might be bad because they were in her hot car. 
@RRay I think the decline might be due to hospital networks going single source and racing to the bottom to get the cheapest things. There's no incentive to make a higher quality instrument/reagent/etc. if the hospital networks are only going to look at upfront costs and ignore the issues caused by low quality/bad service/insufficient supply.

Our Blood Bank uses Hemotemp II's but they are only good applied to the bag for about 2 days. They also have to be activated with a 40C incubator. We use those for units in OR coolers and trauma.
If you want tracking for the life of the unit, Safe-T-Vue's are pretty much the only option.
I second everyone's frustration with the Timestrip BT10's. We tried them for our trauma bay and they fell off all the time despite prepping with alcohol and wiping condensation off the bag. They'd also activate if you looked at it wrong. Our rep said the lots we got might be bad because they were in her hot car. 
@RRay I think the decline might be due to hospital networks going single source and racing to the bottom to get the cheapest things. There's no incentive to make a higher quality instrument/reagent/etc. if the hospital networks are only going to look at upfront costs and ignore the issues caused by low quality/bad service/insufficient supply.

When we were performing electronic crossmatches and had Cerner there was an 'additional units' field built into the product request order. The provider was free to write whatever they wanted in that box but we were never going to look at it.
The nurses would sometimes come down with 'doc wants to make sure we have additional units available', if I was feeling particularly sassy I'd get up, walk over to the fridge, pull out a shelf, make a big production of looking at the units, and say 'yep.'

At my institution. the Donor Network is now asking for 4-6 units of RBCs for organ perfusion for their machine after the organ has been harvested (similar to ECMO for the organ).  Those RBC units will not ever touch the organ donor patient.  Our policy is to always issue them the oldest O Pos units (uncrossmatched) we have on our shelf.  They will rinse all of this banked blood out of the organ before transplanting it into the recipient, and it is added to the perfusate solution to provide oxygenation to the organ during transport from the donor hospital to the recipient hospital.  AABB offered at least 1 very informative session at their annual meeting on this last year in Nashville, and I'm guessing that they will offer more in Houston this year (or perhaps an eCast session or articles in AABB News or Transfusion) since this practice is becoming more and more widespread. The unique nature of the process is proving to be a challenge for hospital transfusion services as far as who places the order, what testing is needed (if any), tracking for final disposition, what kind of records need to be kept because they are not being "transfused", billing of the products, etc..

We had issues with our Visions not reading barcodes also.  We did learn that the Vision needs approximately 4 mm of a white margin on either side of the barcode to read.  We adjusted our barcode printer and that enabled the Visions to read the label.  Not sure if anyone at Ortho told you that.  I think it was our service rep that let us know that hint! Good luck!

Just for the record, I am not aware of any data, nor can I conceive of a mechanism by which red cell transfusion would correct base excess.  This patient apparently had an extensive and severe infection, so vasodilation due to septic shock seems a real possibility.  Transfusing a patient to a hemoglobin of 14.6 is not something I've ever heard experts in anesthesiology and intensive care medicine advocate, and transfusion to this level would be expected to increase the risk of thrombosis greatly.   
And just for completeness, the diagnosis of septic shock in a patient with a recent serious infection and also likely receiving broad spectrum antibiotics does not require the presence of positive cultures for diagnosis.  Hard to grow bugs in vitro when there are high concentrations of anti-microbials.  This is why DNA tests are probably a better tool to diagnose infection in such patients, if available.  Does not require growth, just the presence of bacterial nucleic acids.