LisaM

Thanks, Malcolm and Liz too--that was sort of my rationale, that the antibody was reacting at room temp, the blood will be infused at room temp, and warming it a bit would be an extra caution to avoid having the antibody react, especially where this was a cancer patient; enough problems just having cancer without throwing in antibodies on top of it. It was actually somewhat of a surprise to me, about not writing things on the transfusion paperwork--we write stuff all the time in the way of our initials, date and time when signing it out, if the patient location changes, we just cross off and initial the change after writing the new location, or if it's a split unit, we'll write "Aliquot A or B"--all stuff that is helpful to the physician and infusionist. I don't think we have a policy about the actual transfusion paperwork and making notations on it, and I'll have to look, but where I work, the rules are sometimes made up as we go along, based on what the day shift techs think. I've made notations here and there on the paperwork in the past and have not gotten any flac until now, so that's why I wondered if it was for real or if I was paranoid. So yeah, we really need a policy in place, but I'm not going to be the one to suggest it--it's best to stay under the radar at times, depending on the supervisor's mood. . .

My thought exactly-- I figured it certainly would not harm the patient, and was just a heads-up. All I wrote was "may want to consider use of blood warmer during infusion".

^^Thanks, all! I was just sort of questioning it, and wondering what other places do, because with this particular supervisor where I work, sometimes the line between "is that right" and "is she just picking on me", gets blurred at times. ...

I take care of all the MSDS where I work, and I'm sure I have something, either a sheet or letter of exemption--if you still need something, PM me your contact info with a fax # and I can fax you what I have.

So I have another question related to cold antibodies, and this came up at work just in the last two weeks: I found a cold antibody in an oncology patient, that was not picked up in gel, but was discovered upon investigation of incompatible immediate spin crossmatch in tube. I reran the screen in tube, and also did a cold panel, and sure enough, the cold was only reacting at room temp and colder. I got the crossmatch to be compatible, prewarmed, and when I did up the paperwork for the units, I put a recommendation that a blood warmer could be used during infusion, just as a heads-up, if the patient's doctor wanted to do that, and then our supervisor sort of slapped my wrist on that one. I was told to never write notes on the transfusion paperwork, and a blood warmer should only be used if the cold antibody is reacting at 37 degrees. What do you all think? I don't see the harm in alerting the people performing the infusion, of things that may be helpful to them, and I just figured why take a chance with an oncology patient, regardless of what the antibody is. Basically I think there's a lot worse offenses that can be had in blood bank, and those were minor in comparison to some, but then, too, this supervisor doesn't always like me all the time and I go through periods where it seems like there's fault-finding just for the glory of power and one-up-manship. . . ..

^^Thanks! I'll check the tube package insert tonight when I get to work, to see if it says anything.

Thanks for all the tips, everyone--I'll see what comes of this whole mess; our supervisor has threatened corrective action if anyone signs out a weak positive antibody screen without respinning and retesting. .. . .and I'm going to keep my opinion of that/her to myself.

Edit to my above post: I pulled the samples in question, and ran DAT's on them, because they'd sat in the refrigerator all night before the day shift respun/reran, and lo and behold, they had very weak microscopic positive DAT's. . . .could be something there that adsorbed out overnight, and that's why the day shift got negative screens on repeat. Sooo..... a topic for next week's BB meeting and we'll see what they say about that.

Yes, I remembered my password, Malcolm--LOL I'm bumping this thread because I have a question: we spin our BB samples at 3500rpm for 10 minutes. On occasion, we get a weakly positive antibody screens here and there, and I sign them out as such, along with any antibody ID, be it non-specific, negative panel--which has happened also. My thought is that you spin them once run your tests and it is what it is. Now here's the clincher: the day shift has taken to re-spinning samples showing weak positive antibody screens, either in the original tube or taking off the plasma and respinning that separately, rerun, and lo and behold, the screen is negative. They change the results in the computer to reflect their findings, then send out love notes in the computer, saying that we should be doing that too on the off shifts--respin, rerun. So what does everyone think of that? I emailed AABB with that, and am waiting to hear back from them, but it seems to me like they're forcing it to come out negative in the name of conserving supplies/cost, which is their reasoning for doing that, to not waste antibody panel "needlessly". I don't know if you can "spin away" the antibodies, or if double/triple centrifugation even matters on a blood bank tube--I know it can affect chemistry analytes. Thoughts??

I thought ether-sniffing was only glamorous in the 1800's when they didn't know it could kill you, Malcolm???? LOL And thx for the reply--I thought it was a waste of time, doing the KB. The baby's H+H was something like 4 and 16--really bad, and they shipped it out to a hospital better equipped to deal with trauma like that, but we had to pump some blood into the baby before it was transferred. The mom is a drug addict and Hep-C positive, so I'm sure Social Services will step in, next. . . .

Hi-De-Hoo! Long time, no post, but yes, I did remember my password! Anyway, a question as it relates to this thread: last night we had an emergency transfusion of a newborn, mother's blood type and baby's blood type was A-positive, with a negative DAT on the cord cells. We gave the baby O-neg, irradiated because there was no time to order from the Red Cross, the special packs they make up for neonate transfusions. The doctor wanted a Kleihauer Betke done on the mother, and I wanted to ask if it makes sense to everyone else to order that? I know it's usually done primarily on Rh negative moms to determine rhogam dosing, but where it's actually detecting fetal hemoglobin, would it work the same on an Rh positive mom as far as showing the extent of a feto-maternal bleed?

I think that's already there, because it also states that if the Rhogam history is known, then the 3 @ cells are to be used regardless of whether it's a first time panel, or subsequent one. If there's no history of Rhogam or it's unknown, then we are allowed to do a full, 11-cell panel.

Our procedure states that to rule out Kidds, Duffys, and MNS system, we need only one cell to rule out, but we must always use homozygous cells and never heterozygous. With everything else, if there's one homozygous to rule out with, that's fine, but if not, then 2 heterozygous are acceptable. That's where a bit of a procedural contradiction comes in--some of those @ cells don't allow for the homozygous rule out, yet we're supposed to accept it based on the disclaimer within the procedure of that being ok for the anti-D scenario.

Joan--we run a 2-cell screen, and in gel, as that's our primary. We only switch to tube on occasions when it may be helpful to see those reactions, or we're having a problem workup in gel, etc. Apple--thanks and I agree! I've been running about 6 cells to ensure a cautious rule-out, as the 3 @ cells on our panel do not allow for a homozygous rule out of things such as "S", or both Duffy's or Kidd's. I was being told that that was running too many cells, and it wasn't even a full panel, and to stick to just the 3, but after speaking with the supervisor yesterday, she compromised on allowing one additional cell to make sure both Kidds are ruled out with homozygous cells, as that's the only one she's concerned with.

I've already run this one by Malcolm, by email, but wanted to see what everyone else thinks about it: We've had a go-around at work regarding the procedure for running panels on OB patients with a suspected anti-D. The way our procedure is, if we suspect a D, we are supposed to run only the 3 or 4 "@" designated cells on the panel, and if they're all negative, call it a D and you're done. This is regardless of whether or not it's a first time panel or a subsequent one on the patient. My prior training was to perform a full panel on anyone, any antibody if it's a first time panel, then use selected cells to rule out on subsequent panels, making sure you account for homozygosity on those that can show dosage. All other area labs are doing it this way, and our procedure is being defended as correct because A. All the other labs are automated and have no choice but to run a full panel (which I wonder about. . . ) and B. If there's another antibody there, and it's too weak to react with heterozygous cells on those "@" cells, then it's too weak to titer, too weak to be of concern, and will be picked up later in the pregnancy if it gets stronger. I'm not at all comfortable with this, because I feel it's setting us up to miss something, and cutting corners in the name of saving money on supplies. I've said my peace at work, and the topic and situation have been laid to rest/diffused, so I'm not going to push this one anymore. I'll do as I'm told and only sign my name to them when I have to (stats and other unavoidable sign-outs), but I wanted to toss this out there to see what everyone else's take on it is.

So Malcolm, I notice your "Thanks Given" and "Thanks Received" tallys are almost tied, yet the "received" is a bit less--does that mean that although you're "thankful", you're mostly "thankless" ?????

True, but we aren't a reference lab where I work, and as much as I'd love to get into all the different, odd, and funky things that blood bank has to offer, we must keep it fairly basic, and simplistic for our customers. Not to mention, we don't have all the resources in the way of reagents and supplies to go much further than a certain point; we even send out our warm autos for work-up at the Red Cross because we don't have the means to neutralize them.

I wish, but I don't see it happening. We don't have anyone in our court as far as being a "higher up", that has an extensive knowledge of blood bank, or one enough to vouch for us in instances like this. The BB supervisor has other things on her plate, and I'm not sure if she plans to address this at all at some point, or if it's considered minor in the scheme of things.

^^Thanks, Peter! Aside from opening a can of worms with the Du testing on this particular group of patients and not going with just the gel results, it's also wasteful, cost-wise, and redundant, because 99% of the time, they check through perfectly and agree with the gel. But, we have no choice but to do it this way, per order of the facilities we get the samples from. On our own patients, we don't do that, unless there's some problem/question with the gel.

We've had the opposite happen once or twice, where the gel testing was negative for "D", and it came up positive in tube during Du testing. The only reason that was picked up, was because we get samples sent in from other sites that pay us to do their prenatal type and screens, and they're sort of not with the program a little in the respect that they insist upon Du testing for all Rh negative's, so we have to recheck all negative-D's in gel, by tube and Du. Even though gel is pretty reliable, there's always the occasional exception!

I've wondered that myself, too--we get the 10 ml red top tubes for cord samples, and usually if there's a clot, there seems to be enough cells floating around in the serum, too, to suck out a sample and wash the heck out of it, because they stuff the tubes very full in our L+D department.

Are those reactions from gel or tube methods? I've seen that happen in gel and when rechecked in tube, they're fine. Occasionally, we've had gel reagents get contaminated, and also we've had the "M"-thing happen like someone mentioned above.

Hello and thanks Anna and Malcolm! I called her positive the first time around, because it's our policy to do so when we have a macroscopic reaction, and the computer system makes us choose one way or the other and won't let us sign it out as "Rh negative, Du positive". I did not run a Du the first time, as it was clearly positive, though weak, but did the second time and that came up as a 4+ with the IgG. Our supervisor left it at the Rh positive, since we were seeing positive reactions macroscopically, however weak they were. Unfortunatley with these samples, they are shipped in from another facility, so we have no history on the patients, or any idea what happens to them other than just what we see and report when we type and screen them. I left my antigen typing from last night for the supervisor, to let her decide if she wants to recommend further testing for this patient through their own facility, or just leave things as is. Regardless, I've pretty much done all I can with it, with the means I have at my disposal, and I at least feel confident that I gave as much information as I could and documented it as such.

9pm--Update! Ok, so I antigen typed the patient for C, c, E and e, and she turned up positive for all of them! I called the Red Cross reference lab to consult with them, explained the whole thing, and they said that it's uncommon, but entirely possible to have a phenotype like this. Also, they said to watch the patient, because those with this phenotype are at risk for developing an anti little "f". So that's the update as it stands now!

^^Thanks JP! I'll read out anti-D package insert tonight when I get in to work. I believe it's Immucor brand that we use for that, and we normally only do Du testing on babies, but with the batch that comes from the other facility, they insist upon it, each time we get an Rh negative, and even each time the patient comes in for a repeat type and screen. A bit wasteful as far as reagent, in my opinion, because we primarily use gel for ABO testing, but have to switch to tube just for the Du's on these people. Regardless, our procedure for Du's is to immediate spin them, then incubate at 37 degrees celsius for 15 min, then right into the cell washer with no spin after incubation, then add IgG. We don't (or aren't supposed to) use the microscope except on the babies to verify a negative reaction at IgG phase. I was very confident the first time around with this patient in calling her Rh positive, but was more than a little surprised with the second sample and the decreased reactivity. I was thinking, too, that it might be good to antigen type her for E, C, e and c, just for kicks to see what her set up is. Maybe if I have some time on my hands tonight I'll do that.