Liz0316

You must be a large hospital, getting the NEO, so I'm guessing you need one specific method for everyone to follow. I'm from a much smaller hospital and I'm involved in work ups especially the ones that are inconclusive or troublesome. I like to keep my options open on these work ups. We stock, PEG, LISS and also have a method for a saline 4-drop IAT. Depending on the patient's history and how they are presenting currently, I would use different medium. I wouldn't use PEG on a patient with a WAA - why go looking for it? Or for that matter, on a patient with a cold reacting antibody. Once the antibodies are identified (or lack thereof of a clinically significant antibody) I don't want to use a method that I know will enhance insignificant reactivity for the crossmatch. Of course, if the patient presents again, we start all over again! Liz

Can you remove the status of the units and return them to inventory, then re-issue to the correct patient? Liz

The following is not pretty, but I finally got the indications to copy and paste. This is what we use for indications for irradiated products, which may be more than normal - however, we do have our own irradiator. Questions - let me know. Liz 7. IRRADIATED CELLULAR BLOOD COMPONENTS: A. Accepted indications: 1. Immunocompromised marrow or organ transplant recipients. 2. Patients with hematologic disorders who will be undergoing allogeneic marrow transplantation imminently. 3. Intrauterine transfusions. 4. Neonatal exchange transfusions or use of extracorporeal membrane oxygenation (ECMO). 5. Neonates or pre-term infants. 6. Lymphoproliferative malignancies treated with Fludarabine. 7. Patients with Hodgkin’s disease. 8. Patients with congenital cell-mediated immunodeficiencies. 9. Recipients of directed donations from biologic relatives. 10. Recipients of donations from HLA-matched donors. 11. Recipients who are heterozygous at an HLA locus for which the donor is homozygous and shares an allele. B. Possible indications: 1. Individuals getting immunosuppressive therapy, especially when susceptible to opportunistic infections. 2. Cancer patients who are immunosuppressed because of chemotherapy or radiation therapy. 3. Patients with AIDS who have opportunistic infections.

I have seen anti D developed from platelet transfusion, and recently. However, our policy is not to consider Rh unless the patient is a child (under 25) or a woman of child bearing years (under 50). We do not offer RhIg prophylaxis, unless the patient is a child or a woman under 50. No difference between apheresis and pooled random and I don't consider Kell at all. Liz

Also, the 0.8% Ortho red cells have a preservative in them that may effect patients with allergies to sulfa drugs. I'm at home now, and don't have the package insert in front of me, but the preservatives are different from the 3% cells and the 0.8% "gel ready" cells. Check to see if your patient has a sulfa allergy, that may explain the reaction differences you are seeing. Liz

Let's answer question # 2 first. In any given unit of donated blood, the red cells are of all ages, new and older. So, since the life span of the RBC in the circulation is approximately 90 days, "recently transfused" means that there is a possibility of donor red cells still in circulation in the patient - therefore, foreign antigens are present that could elicit an antibody response up to 90 days (approx.). Question #1 - I think you were correct in requesting another antibody work up. Especially with the severe drop in Hgb. If a patient has been recently transfused - with in 3 months, the specimen is only good to work with for 4 days - the day it's drawn plus 3. Assuming you don't do antibody work ups at your hospital, I believe this patient needed an additional work up at the reference lab. The 3 month rule is because the body can form an antibody to a foreign antigen at any time that foreign (donated) red cells are actively in the patient's circulation. I hope that helps, and I'm sure my reference lab colleagues will have more to say Liz

I agree with Terri - the pharmacy at our hospital is going to stock PCC once the policy for indications is written. We had a patient last Thursday that was the perfect candidate, could have taken him to surgery one to two hours earlier if we had the PCC instead of using FFP. The cost is a lot, but the chief of surgery wants to stock for when he feels it is necessary. Fortunately for us, it will be distributed by the pharmacy. Liz

thanks, David.

I agree, if it is that urgent, hand them the bag and let them take what they need. If the unit is not going outside the hospital, why does the syringe they pull the product into need to be ISBT labeled? Liz

ditto, David.

I agree with Malcolm. An Rho cell is considered to demonstrate a weak D reaction. I would not rule out anti D on the basis of a negative Rho cell. Liz

I agree, I wonder why that positive DAT wasn't detected on admit? I see your point. If it makes you feel better, I presently have 2 patients being worked on in our local reference lab (neither is urgent...)

RaeRae251 - you didn't mention anything about transfusion history. We are a midsized hospital and I only send out when I have to - (sorry Malcom). If your patient has not been recently transfused and you can rule out all the common clinically significant antibodies, cross matches are negative... why send it out? If I recall correctly 9% of the population is walking around with a positive DAT, completely benign. I wouldn't send out any cold reacting antibody if I can get around it, certainly if the patient hasn't been transfused. I definitely won't send out a sample where the auto control is the only positive reaction and the DAT is negative. Now, if the patient has been recently transfused, that is an entirely different scenario and great care must be taken not to overlook any developing antibodies (IgM). But, we use different techniques (GEL, LISS, PEG, and my favorite - 4 drops with no enhancement - yes, I'm older than most). I guess what I'm attempting to say is, we have no "cut and dried" formula for sending out specimens, each case is different. Patient safety first, but follow up with common sense. Just my 2 cents.... Liz

are you just looking for a basic procedure or the indication for? Liz

We get approval from the physician and pathologist and this approval is documented in the LIS.

I agree with Goodchild - we charge both patients.

We report the antibody screen as negative, then add a comment "antibody not demonstrable: anti [ ]".

Wow - this is complicated! In thinking this through, the hospital that issued the units should already have saved the segments from the products. So it would stand to reason, that the issuing hospital should get a specimen, in retrospect. Now, that may not be possible, but what if an emergency release form signed by the responsible person ordering the blood were to make it's way back to the hospital. Then, the issuing hospital would have some demographics on the patient and be able to enter that information in the BB system. I have an emergency release function in Sunquest, where I don't need to enter serologic reactions, but can "issue" blood to a specific patient. Maybe add a comment - "transfused during transport to..." That might give a little more information as to the final disposition of the product?? I'll keep thinking! Liz

If we suspect a delayed serologic transfusion reaction, we will pull the segments from the previously transfused units (if transfused at our facility). We also call other BB if we know the patient may have been elsewhere. Pulling segments doesn't happen often, but hospital hopping patients are frequent. I like as complete a history as I can get when working with a new patient with antibodies. I have been known to call all over the country. Just last month, between 4 in-state hospitals, we were able to follow her right down the coast - making a new antibody with every admission! She now has 3 antibodies and all involved are aware. I'm willing to buy the train ticket out of the north east!

We get a list of patients that have expired within a hospital visit and pull those antibody folders. We also check the obits all the time .... we want to know where our multiple antibody patients are - all the time! Other than that, these antibody folders just hang out in the file....

we report as titer <1

I have been trying to steer my techs away from microscopic reading of DATs - except in a transfusion reaction work up. Fortunately, I have seasoned techs, mostly, and any question of a positive reaction has an eluate done. We are a hospital on the east coast, by the way. Let's not discuss the doctors that order a DAT the day after a transfusion, it gives me a headache! Liz

suhu - thanks for the tip!

We use the shock watch indicators, and had a little trouble at first. I contacted the vendor and received some "tips." The tag can go anywhere on the unit, even on a label when packing, position the units "tag up." The units should be refrigerated for 24 hrs before attaching the tag. This where we ran into trouble: taking a unit out, crossmatching it, then irradiating it (less than 10 min) then packing it resulted in the tags turning blue when they reached the off site location. So now we XM and irradiate, store the unit in the refrig and have the night shift place the tag on the unit at 6 am just before shipping to the cancer center (4 miles away). Sometimes we still have trouble if the unit is needed right away and the patient requires irradiated products.

to add to goodchilds response, I would do an elution just to prove there is nothing else in there. I would also do it now, before another transfusion becomes urgent. Since you don't do eluates on site, you don't want to have this happen at 2 am....