seraph44

We used to have Typenex but we removed them since they were causing more problems than anything. We collect two specimens to verify we have the correct patient, if only one sample is drawn, we give group O until we have a second sample collection. We also allow for the use of a hematology specimen to verify our blood type. 

Hi Scott,
This is what they are stating here. Which tells me that they are not checking the blood before it gets hung. They say they use a white board but I'm almost certain they are not checking the blood with the white board and I don't think that's acceptable (I can't find literature on this at least). I'm concerned because several times they send a courier that is not involved with the case to pickup blood and if there are two patients receiving blood and the courier takes it to the wrong room, this can lead to some serious issues if they don't properly check the patients and the blood. 

Most references do not use the single symptom of increased BP to indicate a TACO reaction. They usually list a variety of symptoms in which a combination of 3 or more of the following need to be present: 
Increased BP, Respiratory distress (dyspnea), Acute or worsening pulmonary edema via xray, tachycardia, jugular vein distension, increased BNP (brain natriuretic peptide), response to diuretics......
It's up to your facility to decide what kind of criteria you want in your policy. In any case I would think this is important to note in the patient's file since the patient receives dialysis and would probably need to be transfused sitting upright and very slowly if this is indeed a TACO or TACO-like reaction for future transfusions. 

TACO is congestive heart failure.  Hypertension is not congestive heart failure, but may be of concern.  Transient rises in the range of 170 to 200 that last minutes, not hours, are usually not of concern.  That can happen with rapidly climbing a flight of stairs.

The forward type is an AB patient, your reverse type looks like you have multiple things going on. Because of the negative xm with group O donor red cells and the 1+ reactions with your group A donor red cells, I suspect an anti-A1. However, that 4+ reaction on the B cells cannot be due to the anti-A1 and I highly doubt that it is due to rouleaux; At least from my experience I don't typically see rouleaux this strong and we should have seen it with similar strength against the A1 cells. I agree that you probably have a cold reactive allo antibody going on with the B cells.
In order for you to clear the ABO discrepancy I would do an IS antibody screen and see if you find a patter for a common cold antibody. Hopefully your find something; if you find a Lewis antibody I would find some random group B units and you should statistically land on one that can give you a negative result against your patient plasma to confirm it is not an ABO incompatibility issue. If you find something like an M, you could antigen type a group B unit but that will take 5-6 units before you find one, and then test it again your patient plasma to confirm negative results.
The easier way out is to prove your anti-A1 and then take your reverse cell testing to the AHG phase to rule out ABO incompatibility. Consult with your pathologist of course, since this might be out of your standard operating procedure. 

The forward type is an AB patient, your reverse type looks like you have multiple things going on. Because of the negative xm with group O donor red cells and the 1+ reactions with your group A donor red cells, I suspect an anti-A1. However, that 4+ reaction on the B cells cannot be due to the anti-A1 and I highly doubt that it is due to rouleaux; At least from my experience I don't typically see rouleaux this strong and we should have seen it with similar strength against the A1 cells. I agree that you probably have a cold reactive allo antibody going on with the B cells.
In order for you to clear the ABO discrepancy I would do an IS antibody screen and see if you find a patter for a common cold antibody. Hopefully your find something; if you find a Lewis antibody I would find some random group B units and you should statistically land on one that can give you a negative result against your patient plasma to confirm it is not an ABO incompatibility issue. If you find something like an M, you could antigen type a group B unit but that will take 5-6 units before you find one, and then test it again your patient plasma to confirm negative results.
The easier way out is to prove your anti-A1 and then take your reverse cell testing to the AHG phase to rule out ABO incompatibility. Consult with your pathologist of course, since this might be out of your standard operating procedure. 

The forward type is an AB patient, your reverse type looks like you have multiple things going on. Because of the negative xm with group O donor red cells and the 1+ reactions with your group A donor red cells, I suspect an anti-A1. However, that 4+ reaction on the B cells cannot be due to the anti-A1 and I highly doubt that it is due to rouleaux; At least from my experience I don't typically see rouleaux this strong and we should have seen it with similar strength against the A1 cells. I agree that you probably have a cold reactive allo antibody going on with the B cells.
In order for you to clear the ABO discrepancy I would do an IS antibody screen and see if you find a patter for a common cold antibody. Hopefully your find something; if you find a Lewis antibody I would find some random group B units and you should statistically land on one that can give you a negative result against your patient plasma to confirm it is not an ABO incompatibility issue. If you find something like an M, you could antigen type a group B unit but that will take 5-6 units before you find one, and then test it again your patient plasma to confirm negative results.
The easier way out is to prove your anti-A1 and then take your reverse cell testing to the AHG phase to rule out ABO incompatibility. Consult with your pathologist of course, since this might be out of your standard operating procedure. 

Now this question has been revised by CAP:
 
TRM.40780 "There is a written procedure to identify all potential candidates for Rh Immune Globulin".
I don't have much problem with the Postpartum ones - I have a good Cord Blood procedure and process in place to make sure that the Rh Neg moms of Rh Pos babies receive their doses.  The place where it might slip through is the ED/OR if a miscarriage or ectopic came through and Blood Bank was not aware that it was a pregnancy.
In the explanation it says "....the institution must ensure that all Rh-negative women receive the maximum protection against Rh immunization..." 
So it appears that this piece should fall on the providers - to determine Rh type when a patient comes in with a miscarriage or ectopic or other fetal bleed situation.
I can't find any such policy in the hospital SOP's but perhaps I am not digging deep enough.

It does drive me insane that we are expected to wipe their backsides for them... I mean, it is their responsibility to request blood products - we don't say 'oh the Hb is 45, let's issue a few units', so why are we expected to tell them to give Anti-D?

The easy answer on a practical note is as long as the Emergency Release order has been signed by the physician who placed the order all is well in the BB.
My understanding, from when I worked at a level I trauma center, is that once the patient is in the OR; the anesthesiologist is in charge and is not required to finish the transfusion orders of the ER physician. If the anesthesiologist wants to transfuse the remaining uncrossmatched unit they cancel the ER order (if electronic) and place their own when things calm down. This has to do with billing, transfusion criteria and removes ambiguity.
As long as your policy ensures that any physician ordering/transfusing  Emergency Release products is documented in case they need to justify their decision.

The provider who requests the Emergency release of the 2 units is who is asked to sign/take responsibility for the uncrossmatched blood, not the provider (usually surgeon or anesthesia) who gives the Transfuse order. However, we would make sure that the surgeon (or anesthesia) was aware that the unit being transfused was uncrossmatched - he/she could then determine whether or not they wanted to continue with the transfusion or wait for the crossmatch to be completed. We are a level III trauma center and this has not been an issue with TJC, CAP or the trauma surveyors from the state up to this point. You should probably check for regulations in your state, as a start.

It's all electronic orders here, so the ER physician would be initially responsible; but the OR surgeon or anesthesiologist are responsible for any transfusions there, including uncrossmatched units.
Scott

We do as your new supervisor states but without the DAT (unless the autocontrol is positive). An even when a patient has a history of let us say, little-c, we only run the cells that are little-c negative. By this time you should have done a screen and determined that little-c was still present. Anyway, this will allow you to waste time on cells that will ultimately be positive and not useful to rule out the other clinically significant antibodies. There is no need to re-identify little-c again anyway, since you have a history and are required to give little-c negative red cells. 

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html
There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. 
The Case Definition gives physicians and pathologists a criteria they can  use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive:
New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:
 Acute respiratory distress (dyspnea, orthopnea, cough)
 Elevated brain natriuretic peptide (BNP)
 Elevated central venous pressure (CVP)
 Evidence of left heart failure
 Evidence of positive fluid balance
 Radiographic evidence of pulmonary edema
 
It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined. 
 
 

I am a little worried about the fact that there is no serological cross-match if the mother has made an atypical antibody.  The reason I say this is because it is well-known that when a person makes one antibody, they often make more than one.  If a mother makes, for example, an anti-K, which is easily detected, she may well also make another antibody specificity, such as an anti-Dia.  As the Dia antigen is a low prevalence antigen in most populations, it could well be that the Dia antigen is not expressed on either the screening cells or the antibody identification panel cells - in other words, it may not be detected.  Even if the baby does not express the Dia antigen on its red cells, the maternal anti-Dia will still go through the placenta, and so this anti-Dia will still be in the baby's circulation.  If, the unit to be transfused is K-, but Di(a+), the baby could well have an unexpected haemolytic transfusion reaction, which could be avoided by a serological cross-match against the mother's sample.  Once the unit has been cross-matched, and found to be compatible, then aliquots from the same unit of blood can be safely transfused without a further cross-match, but I feel that, for the first transfusion from any unit of blood, a serological cross-match should be performed.

No previous history on patient then do immediate spin crossmatch with type "O" blood until type is confirmed on 2nd specimen drawn at a different time form the original BB specimen. Once type is confirmed then electronic crossmatch with type specific units

In the US we have been doing what you say is going to be the new policy for many years, except we only would do a DAT if the autocontrol was positive.  I think that approach is pretty common.  Orthos' panel A is for the ijnitial assessment.  Most of the time, you will have a pretty good idea what you are dealing with with those results.  Then, going by the 3 x 3 rule, w use other panels for rule-outs / rule-ins.  Also, if there is no history, we antigen-type the patient for those antibodies that are being made.
Scott

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html
There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. 
The Case Definition gives physicians and pathologists a criteria they can  use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive:
New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:
 Acute respiratory distress (dyspnea, orthopnea, cough)
 Elevated brain natriuretic peptide (BNP)
 Elevated central venous pressure (CVP)
 Evidence of left heart failure
 Evidence of positive fluid balance
 Radiographic evidence of pulmonary edema
 
It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined. 

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html
There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. 
The Case Definition gives physicians and pathologists a criteria they can  use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive:
New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:
 Acute respiratory distress (dyspnea, orthopnea, cough)
 Elevated brain natriuretic peptide (BNP)
 Elevated central venous pressure (CVP)
 Evidence of left heart failure
 Evidence of positive fluid balance
 Radiographic evidence of pulmonary edema
 
It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined. 
 
 

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!

We would do an extended Gel XM as long as the current screen is positive.  It's required by the LIS.  The computer system disqualifies them for electronic XM in this instance.  If the screen becomes negative in the future, they would qualify for electronic XM as the antibody is classified as not clinically significant

The AABB TM, 18th edition, states in Chapter 22, Perinatal Issues in Transfusion Practice, Serology and Mechanism, "Administration of RhIG during pregnancy may produce a positive antibody screening result in the mother, but the titer is rarely greater than 4 and thus poses no risk to the fetus."
If we ID anti-D in prenatal sample, we perform a 1:4 dilution and if the results are non-reactive we have two statements in our report, "The antibody demonstrated a titer of less than 4 in saline at AGT indicating that it may be due to recent administration of RhIG."  and "Due to the recent administration of RhIG, the antibody may have been passively acquired. To establish this as the sole cause of the antibody's presence, repeat testing six months post-delivery should demonstrate a negative antibody screen."

In uk if quantification level is 0.4 IU/mL or above we consider as a immune anti-D and we do not issue RhIg.  However if lady comes in ED we perform Group and antibody screen before we issue RhIg.

I see your point SMILLER/Scott. It's a fair argument. I'm not advocating "less oversight", but merely acknowledgement that an immunohematology work-up often has a lot more "grey/gray" than the other pathology disciplines. As we all know, "antibodies don't read books" and sometimes it takes all of your resources and experience to resolve a serological problem, including the prudent use of expired materials (or frozen inventory).
One could argue that absolute prohibition of using expired reagents in such cases could potentially put a patient at more risk by leaving an issue unresolved. Using all of your tools, in-date or otherwise, to get a good answer might outweigh the regulatory implications.
As I alluded to earlier......I don't recommend front-line techs use expired reagents willy-nilly - they should be used surgically and by those skillful enough to recognize the limitations.

Coming from a reference lab perspective, we couldn't do our job if we didn't use some expired reagents.  We have 2 LN2 tanks that hold our library of rare cells.  It has taken our lab over 40 years to accumulate these resources.  In some cases, our cells are from the propositus the antibody/antigen was named after and the donor is no longer alive.  You can't get most of these cells commercially.
In some instances, it appears that regulating groups try to control something just for the sake of control.  Control of a service/technique doesn't necessarily make it better quality, it just makes it more expensive or prohibitive to provide.  Immunohematology isn't like chemistry, hematology, urinalysis, etc.  It's not as easy to put this part of the lab in a box.  At least, that's my opinion.
And there is no such thing as a "mere generalist".  There is much to keep track of when you are working in several different departments; that's no "mere" feat.