PammyDQ

Hi Cliff, 
In response to the email reaching out for posts, I decided to log in again. I began in the group 15 years ago when it was Blood Bank Talk. It'd been a while since I logged in so I had to re sign in thanks to your prompt.  I am 99% sure I had always used my user name to sign in, not email,  but I was not allowed to enter anything that in the field without an "@" . I tried my email addresses unsuccessfully. I was able to gain access by doing a password reset and was then automatically in. I went to edit profile and I don't even see my email address to update as it was changed by our hospital (but I can still receive mail sent to old address as it automatically goes into the new mail)
I do appreciate this site, but will admit I'm distracted by pages on the social media platforms where I spend more time. I suspect I'm not alone here. 

I just answered this question.

My Score PASS  

I am answering the moderator's call to answer lingering unanswered posts. So here I go...
Our thresholds vary by circumstance. We do marrow and stem cell transplants and have an active cancer center, therefore use a lot of platelets. Conservation is imperative so we strictly monitor their use.
For the autologous transplants, our criteria for prophylactic platelet transfusion is <5. For allogeneic it's <10. We also use the immature platelet fraction to determine whether the patient's marrow is recovering which might lead us to being more conservative if they're trending up. If they're febrile, septic, bleeding, having an invasive procedure, on certain anticoagulents then they may raise the threshold. Some non-BMT oncologists are more liberal with platelet transfusions for their outpatients, often using 20 as a minimum.
For the general patient population, we are also restrictive, but try keep transfusions below 10. But again, the overall picture will determine if we choose to question/restrict their order. 
For ITP, we suggest no platelet transfusion unless they're bleeding. They need to be treated with corticosteroids.
Our Medical Director publishes a pocket guide with many different aspects of transfusion medicine. Data is based on Circular of Information, standards, peer reviewed studies, AABB, FDA, etc. It's given to the house staff every year. It's very handy and we can remind the docs to check page so-and-so if they order something we question. 

I would just like to add one 'grain of salt' to this debate.  You cannot detect all D variants - whether D weaks or partial Ds by serological methods alone. Neither D weaks or Partial Ds behave in a way that allow one to say that all D weaks  or partial Ds react with such and such a strength.  You will always miss some.  You will miss some D+ donors because their D antigen is so weak that it is not detected by even the most sensitive of routine serological tests - or because despite using at least two different monoclonals the donor has an extremely unusual variant that is detected by neither.  You will miss some 'D-neg' patients  because they have sufficiently large numbers of D-antigen sites that they give a normal reaction with the anti-D reagents used.  Follow the manufacturer's instructions for the reagent and method used and you will detect as many as you can hope to detect.  And before you shoot the manufacturers because their reagent/instrument gave a 4+ reaction with a partial D known to have 10'000 D-antigen sites per red cell, and discovered because the lady made an anti-D and she is pregnant - please take a minute to think about the theory behind the serology.  Maybe in years to come there will be a foolproof routine method for catching every single one……...

Category III partial D's are known to type just like regular D positives but are capable of making anti-D right?  There is no perfect test for who can make anti-D and the nomenclature is a confusing mess!

Do people call antibody screens negative if they are 1+ or 2+?

If it's positive in gel, we consider them positive. It's been that way at this facility since we went to gel in 2004. We haven't see any complications because of it, but then with our volumes we probably wouldn't. Probably the majority of our daily testing is prenatal type and screen testing from our doctors office. We don't have a huge daily volume though. A dozen separate patients would be about as busy as we'd get. I would say most of our patients are pretty healthy with strong antigen expression. I don't see many below 2+ on them. We only weak D test cord bloods.
Isn't it the general statistic that 16% of Rh neg mothers will develop anti-D without RhIgG? You can probably run the numbers on how many you have that test at 1+ and 2+ and then check their results against any DNA testing you've done. You might find that the low the percentage may not be worth the extra fuss. I believe I heard the number of people having just one child is increasing. Huge world of statistics to consider!

In my house, the cake would not make it to the next day.

I am enormously honoured to announce that I am going to be awarded the Gold Medal of the British Blood Transfusion Society at their Annual Scientific Meeting in Brighton this year.  It is awarded to an individual for their exceptional and long standing services to the Society and to the practice of blood transfusion in the UK.  Sorry if this sounds egocentric, but I am very excited.

Our Preop patients are TS only. Then when they come in the day of their procedure, the orders are entered (by the amb surg dept) for the products requested on that day's admission. The date of surgery is considered DAY 1 for the preadmission TS sample (even though it's entered for the actual collection date) and that specimen's crossmatches reflect that date and will have a 72 hour life at that point. We have Meditech also (:mad:). If the patient is not crossmatched that day and then the next day on the floor they order a unit, the specimen is now 1day old and we'll backdate the product order to reflect that, etc. Our preop TS specimens are good for 14 days. If the surgery is done on the 14th day, then the specimen could not be used on the 15th day and a new TS will have to be done. If the patient was recently transfused or pregnant, then a new TS specimen will be requested on the day of surgery, a new IAT performed as a confirmation that no previously undetected antibodies have formed, but all off the books (no order or charge) but results documented in BB.
We in BBk, having a copy of the surgery schedule and the signed preadmission testing document signed by the patient which notifies us of any recent transfusions or pregnancy. If the patient has an antibody, we automatically crossmatch 2 units the day before to save time.
Also, the day before surgery we call the ambulatory surgery department to notify them of any patients that require a 2nd specimen for ABO confirmation. When the patient comes in the next day, they obtain the specimen when they start the IV etc.
We also scan the surgery schedule for any patient that may not have a TS yet are having a procedure that normally warrants one. We'll notify the amb. surg. dept. as a courtesy that they may need to order one.
It's worked out quite well for us. I hope this makes sense, it's a rather simple system that appears complicated when describing it.

It's very common for a weak/partial D person to react strongly with gel and weak or negative with I.S. tube method. I even had one today! Remember, the reagent anti-D in your bottle and the anti-D in your Monoclonal ABD card are not from the same clones used in manufacturing. And it's not the methodology because before the prepared monoclonal ABC cards we used to make our own with the buffered gel cards...but didn't see the different reaction patterns until patients returned after us getting the monoclonal cards. And now we do our 2nd confirmatory with 2nd specimen by tube method so we see patients with "discrepant" strengths when they're a weak D. That said,  with a 4+ in gel (your subsequent workup) and a 1+ in tube (from the initial workup) I would venture to guess the child is a weak or partial D.
Next issue...As far as the 1st case of gel testing shown, with the agglutination with Anti-A, Anti-B, anti-D and the control, I suspect the diluent. I've been using gel for greater than 16 years, yet over the past couple years we're having problems with the Ortho Diluent 2 getting funky at the end, and reacting exactly like that, sometimes only affecting one specimen in the batch. It's possible if you made a new suspension with fresh diluent you may have not seen that and the typing was unrelated to the antibody screening. Or perhaps the patient cells needed washing because they were coated with whatever was causing your positive screen.
So, my suspicion is that the child had a typical case of WAIHA that had nothing to do with his D type, and he was successfully treated with steroids and/or other drugs before returning for the follow-up workup.
 

It's very common for a weak/partial D person to react strongly with gel and weak or negative with I.S. tube method. I even had one today! Remember, the reagent anti-D in your bottle and the anti-D in your Monoclonal ABD card are not from the same clones used in manufacturing. And it's not the methodology because before the prepared monoclonal ABC cards we used to make our own with the buffered gel cards...but didn't see the different reaction patterns until patients returned after us getting the monoclonal cards. And now we do our 2nd confirmatory with 2nd specimen by tube method so we see patients with "discrepant" strengths when they're a weak D. That said,  with a 4+ in gel (your subsequent workup) and a 1+ in tube (from the initial workup) I would venture to guess the child is a weak or partial D.
Next issue...As far as the 1st case of gel testing shown, with the agglutination with Anti-A, Anti-B, anti-D and the control, I suspect the diluent. I've been using gel for greater than 16 years, yet over the past couple years we're having problems with the Ortho Diluent 2 getting funky at the end, and reacting exactly like that, sometimes only affecting one specimen in the batch. It's possible if you made a new suspension with fresh diluent you may have not seen that and the typing was unrelated to the antibody screening. Or perhaps the patient cells needed washing because they were coated with whatever was causing your positive screen.
So, my suspicion is that the child had a typical case of WAIHA that had nothing to do with his D type, and he was successfully treated with steroids and/or other drugs before returning for the follow-up workup.
 

I would say that the request for the titre is a conservative 100, 000%!!!!!!!!!!!!!!!!!!!!!!!!
 
 
I agree - I've had OB docs ask of "I" negative blood !!!

One more thing to remember and has been discussed before in this forum-- any labels stuck to blood components have to be FDA compliant with regards to the adhesive used. Avery labels are not approved for affixing to blood component bags. Shamrock is one label Co. that I know that has blood bank labels that have approved adhesive (it is stated as such in their catalog). There are probably others.

It's been a VERY long time since I've done neonatal blood banking, Steve was correct as usual to cite the regulations. And kudos to Malcolm for the correction on their improper terminology...I didn't catch that!
That said...
In this hypothetical scenario, there is no mention whether the anti-c is Ig-M, Ig-M & Ig-G or Ig-G exclusively, and depending on the methodology used you may not know. I'll assume we're talking Ig-G only.
This would make me believe that mom had a low/undetectable titer of anti-c from a previous sensitization which was spiked by this pregnancy/birth (assuming mom wasn't transfused at delivery) and subsequently detected a week later.  So, that would lead me to believe that baby is in fact c+. Since mother's screen was negative at birth, any maternal antibodies in the baby's circulation would be at a very low titer if any were present at all, evident by the negative DAT. Baby would also have a negative antibody screen. This would exclude the necessity of transfusing c- negative units.
  If in this scenario they wanted to transfuse the baby at a week old, could not obtain a baby T&S, and mom's current blood was used for pre-transfusion workup/crossmatch, THEN you'd need to honor her antibody in order to have compatibility with mom, and hence transfuse baby c- RBCs.
(In my experience with neonates at 3 facilities, any baby requiring transfusion would have a Type & Screen performed on their own peripheral blood, we never used mother's.)

It's been a VERY long time since I've done neonatal blood banking, Steve was correct as usual to cite the regulations. And kudos to Malcolm for the correction on their improper terminology...I didn't catch that!
That said...
In this hypothetical scenario, there is no mention whether the anti-c is Ig-M, Ig-M & Ig-G or Ig-G exclusively, and depending on the methodology used you may not know. I'll assume we're talking Ig-G only.
This would make me believe that mom had a low/undetectable titer of anti-c from a previous sensitization which was spiked by this pregnancy/birth (assuming mom wasn't transfused at delivery) and subsequently detected a week later.  So, that would lead me to believe that baby is in fact c+. Since mother's screen was negative at birth, any maternal antibodies in the baby's circulation would be at a very low titer if any were present at all, evident by the negative DAT. Baby would also have a negative antibody screen. This would exclude the necessity of transfusing c- negative units.
  If in this scenario they wanted to transfuse the baby at a week old, could not obtain a baby T&S, and mom's current blood was used for pre-transfusion workup/crossmatch, THEN you'd need to honor her antibody in order to have compatibility with mom, and hence transfuse baby c- RBCs.
(In my experience with neonates at 3 facilities, any baby requiring transfusion would have a Type & Screen performed on their own peripheral blood, we never used mother's.)

This may be a silly question...but are you sure he understands the difference between pheresis and random donor?  The vast majority of our physicians still order 5-6 packs of platelets even though we have only carried pheresis for 10+ years.

While I stick-by my answer above, as always there are exceptions and this topic is no different....
Long Answer: Maybe
The AABB Technical Manual and the "Standards" state: "The serum or plasma of either the neonate or the mother may be used to perform the test for unexpected antibodies..." (5.17.1).  It goes on to state: "If the initial antibody screen demonstrates clinically significant unexpected red cell antibodies, units shall be prepared for transfusion that either do not contain the corresponding antigen or are compatible by antiglobulin crossmatch until the antibody is no longer demonstrable in the neonate's serum or plasma." (5.17.1.3)
In this situation, if the transfusion service were to go the ultra conservative route and choose to use ONLY the mother's serum or plasma in their pretransfusion testing, then YES, they would be forced to select c- units as that would be the only unit that would be compatible with the mom's (or mum's) serum or plasma. 
If they choose to use the neonate's serum or plasma, then we are back to the "short answer" answer above, and NO, c- units would not be required.
 

With all due respect to the AABB Technical Manual and the "Standards", a unit cannot "contain" the corresponding antigen!  A unit can "express" the corresponding antigen, but it cannot "contain" the corresponding antigen.  After all, red cell antigens are "expressed" on the surface of the red cell membrane (even those, such as Ch, Rg and Lewis, that are adsorbed on to the surface from the plasma are still "expressed" on the surface of the red cell membrane), and antibodies sensitise these surface antigens, rather than being absorbed into the cytosol of the red cell and sensitise red cell antigens "contained" in the red cells of the units.
 
One would have hoped that such a eminent organisation would have got that correct!!!!!!!!!!!!!!!!
 

We have 2 brand new Hettitech/Helmer SeroSpin®-FA-280s.  The FA rotor has a maximum of 5000 rpm but we're using 3500 for serological testing. We also purchased a separate 12 place blood separation rotor to use for spinning the samples (we spin at the bench). The maximum RPM for that extra head is 6000 and we have ours set to spin at 5000 for 5 minutes and get nice separation. The centrifuge knows which head is in. I've never heard of a 80,000RPM centrifuge! That's crazy fast! Or a typo?

Our ThermoSafe coolers use 3 frozen coolants and two refrigerated cool packs. They keep the temperature under 6 degrees for up to 8 hours.

We have 2 brand new Hettitech/Helmer SeroSpin®-FA-280s.  The FA rotor has a maximum of 5000 rpm but we're using 3500 for serological testing. We also purchased a separate 12 place blood separation rotor to use for spinning the samples (we spin at the bench). The maximum RPM for that extra head is 6000 and we have ours set to spin at 5000 for 5 minutes and get nice separation. The centrifuge knows which head is in. I've never heard of a 80,000RPM centrifuge! That's crazy fast! Or a typo?

We are a community hospital with a bone marrow/stem cell/cord blood  transplant center. Our blood bank medical director is Dr. Joseph Sweeney (you can look up his illustrious credentials). He has recommended that  patients receiving fludarabine, bendamustine, claradibine, deoxycoformycin, alemtuzumab, anti-CD52, and campath within 2 years should receive irradiated blood products, but made our policy that they receive irradiated products for life. We usually only deal with fludaribine, but lately bendamustine is being seen a lot.
While the transplant team includes blood bank in their weekly meetings, sometimes communicating the meds can be missed. We now have a program in our HIS that when the pharmacy is dispensing these drugs, a printout comes to blood bank so we know and we put an irradiated product marker in our LIS.

We are a community hospital with a bone marrow/stem cell/cord blood  transplant center. Our blood bank medical director is Dr. Joseph Sweeney (you can look up his illustrious credentials). He has recommended that  patients receiving fludarabine, bendamustine, claradibine, deoxycoformycin, alemtuzumab, anti-CD52, and campath within 2 years should receive irradiated blood products, but made our policy that they receive irradiated products for life. We usually only deal with fludaribine, but lately bendamustine is being seen a lot.
While the transplant team includes blood bank in their weekly meetings, sometimes communicating the meds can be missed. We now have a program in our HIS that when the pharmacy is dispensing these drugs, a printout comes to blood bank so we know and we put an irradiated product marker in our LIS.

Yes, is the simple answer kmmoton, but be careful.  As you are no doubt aware, anti-Jka can be extremely labile, and will find any excuse not to play by the rules!!!!!!!!!!!!!!!!!!!!