klsmith

We used to start with O pos for males over the age of 18 and women past child bearing age, but we don't do that anymore. We have actually given quite a few patients (ironically the majority of them being male!) an anti-D. We went back to giving O neg to all trauma patients. If the patient gets to the point where they take up to 5 or 6 units, we then convert them to Rh positive, with pathologist consent (unless we have a type by that time, and then we give type specific).

We used to start with O pos for males over the age of 18 and women past child bearing age, but we don't do that anymore. We have actually given quite a few patients (ironically the majority of them being male!) an anti-D. We went back to giving O neg to all trauma patients. If the patient gets to the point where they take up to 5 or 6 units, we then convert them to Rh positive, with pathologist consent (unless we have a type by that time, and then we give type specific).

Well you carry on doing just that then klsmith, seeing as you had ONE example where it came up with something that would have otherwise been missed, and you clearly think that that justifies it. Actually why not put up enzyme IATs routinely as well.   But please do not complain when you have to put up panels on 90% of your samples and get inconclusive results on all of them
I am not complaining, nor am I the tech who discovered the antibody by the means which you say are incorrect! I am just telling you what I have witnessed by a reputable tech. BTW, how do you know that this situation doesn't happen more frequently than you are aware of?? Sometimes you really do need to think outside of the box, perhaps not everything is as cut and dry as we would like for it to be....

I'd say that you have to consider the capabilities of your staff. I do ask my techs to use the microscope for DATs. They are all generalists and their time in blood bank is limited. Some of them shake too hard, in spite of my best efforts to fix that problem. They use a mirror, but some don't use a mirror well. So, in order to not miss weak positive reactions they use the scope with a tube roller. We also have a definition for microscopic agglutination (right out of the Technical Manual) that says it is a clump of 4-5 cells (though I do tell them that they should be cautious with this - if tests look suspicious, check them out, don't blindly ignore what you see). When I train, I stress the difference between a clump of cells that are friendly/kissing and a clump of cells that 'love each other' (agglutination). They do very well - false positives are rare. I don't see a lot of unnecessary work being done.
 
 

I would do a bit more work on it.
There are two things I would do.  Firstly, I would incubate a 4oC (but would include a group O cell in the reverse in case there is a "cold" auto- or allo-antibody there).  Secondly, I would papain or ficin treat the reverse red cells (including a group O cell again as a negative control).
As long as the group A and group O red cells remain negative, and the B cells react more strongly, but not as strongly as normal, I would be happy to call it a group A.

Malcolm,
Thank you for your attempt at explaining this to me, you are awesome as always! I am actually shocked to hear that you have not stumbled across a B subgroup, as you have seen and done pretty much everything in the Blood Bank!!!
~KS
 

I also want to just add, that the Provue used to give like 2+ reactions for weak D patients, but this IS NOT the case with the vision at all!
 

OK - to clear up some confusion  (apologies for it being so late in the day!).
Ortho in Europe has glass beads.  Ortho in the States has gel which is similar to but not identical to the Bio-rad (ex-DiaMed) gel.  As the original question was about Kidd antibodies, I will stick to that.  You all know that Kidd antibodies love playing hide and seek.  BOTH techniques will miss some Kidd antibodies - but not necessarily the same ones.  So you might see some antibodies coming up in Ortho and not in Bio-Rad; and you will see others that do the opposite.  And by the way, Immucor will pick up Kidd antibodies that no one else does but it's not sure that these are real but might be artefacts caused by Paraben.  It is fair to say that some antibodies just 'prefer' one system over another.  But across the board, it evens out.

We start with one panel (or cells 1-10 of Immucor's Panel 20 if doing tube testing). If a specificity is apparent when crossouts are done/the pattern of reactivity is reviewed, then we use selected cells (negative for the antigen the antibody reacts with) to complete rule outs OR if a number of rule outs are needed, run another panel on the Echo. If the patient has a more complex history or the antibody screen looks more complicated, we might choose to run 2 panels on the Echo right away. I require 3 antigen positive cells which are reactive and 3 antigen negative cells which are non-reactive to 'prove' specificity. The patient is antigen typed for the specificity identified if not previously typed for that antigen and if not recently transfused. Other common clinically significant alloantibodies are ruled out with 2 cells. This works well with straight forward, single specificity samples with antibodies like anti-K, anti-E, anti-Fya, etc., which are the majority of what we see.  If the antibody screen on the Echo is positive in all three cells, which happens occasionally, we run a tube/PeG screen with an autocontrol plus one panel on the Echo with some questions in mind - is it an autoantibody? is it solid phase speficific? is it multiple antibodies? is it directed against a high incidence antigen? could there be a drug involved (anti-CD38, I'm looking at you!). If the auto is positive, we do a DAT.
If the specificity is not readily apparent, then we run another panel, or two, or three as needed, based on what the first panel looks like. Almost all of our IDs start on the Echo and those panels are pretty well designed for rule outs of the common offenders. It is not uncommon to use only one panel for some specificities. I encourage everyone to look at the big picture, then narrow their search based on what they see. In the long run that will save them time (and reagents). And I will admit that on a busy day, we may put 2 panels on the Echo and push GO to expedite things a bit. If we are doing tube testing, running extra panels we may not need up front, is probably going to use more time and effort.
Change is uncomfortable, especially for blood bankers, but give it shot. Think the steps through and work smart. You'll start to see problem solving in a way that you hadn't seen it before. Ask your work buddies for a second opinion if you're not comfortable. Review some cases with your supervisor to really get a good feel for what he/she is asking you to do. Once you've worked through the process it a few times, you'll feel better about it. And for those ugly case - the folks at the reference lab are your best friends!

Hi Janet,
It seems to me that perhaps you are having an issue with having to perform DAT's. Please take into consideration that the hematologist knows what that he/she is doing. I am not trying to be difficult, but I guess that I do not see what the issue is. Hematologists are Hematologists for a reason, and we have to have faith that they know what is going on with their patients, so that we can provide the best and most accurate results for them! Just saying...
~KLS