dbarding13

Hello All!
I know this subject has been discussed extensively.  It continues to be a source of confusion in my TS, due mostly in part to the lack of solid Blood Bankers (all generalists who rotate through).
Currently, our SOPs for working up suspected cold agglutinins include a "cold screen" at 4 degrees using Immucor Panoscreen I and II, and patient autocontrol.
If Cold Screen is indicative of a cold Autoantibody, a Tube Pre-warm screen is performed, and subsequent panel, if warranted.
This is so confusing to my techs.  Last night I received a call at home from my 2nd shift tech, saying she had a patient coming in for transfusion for one unit of red cells, with no prior history with us, was found to be A+, Negative antibody screen in solid phase on Echo, BUT positive Immediate spin crossmatches.  She then proceeded to tell me she "prewarmed the crossmatches and then they were fine."  She wanted to know how to result the Cold Auto!!!!!!!!!!!!!!!
After swallowing to remove my heart from my throat, I explained that this was not a conclusive "work-up" for a Cold auto.  I talked her through the possibility of Rouleaux (She said she only saw "clumps" not "coins" microscopically); the possibility of an A2 or subgroup, but she assured me the reverse reactions were consistent with A.  I then told her the series of procedures to follow for a suspected cold agglutinin, all of which are in our SOPs.  I suspected Rouleaux, and asked her to follow the saline replacement procedure, explaining that if it was true agglutination, saline replacement would not "correct" it.  She performed saline replacement and the IS crossmatches were as smooth as silk. 
 
I guess my question is, does anyone have any suggestions for making this more clear to our staff?  Also, what are your procedures for identifying a cold agglutinin, or autoagglutinin, both specific and non-specific?  How about a flow-chart to make it easier for techs to determine what to do next?  Any info, SOP, chart anyone is willing to share will be so appreciated right now, and worth its weight in GOLD!!
Dawn

Scott,
Here is our procedure.  I removed our "identifying" information, so feel free to use anything you need!
Dawn
Liquid Nitrogen and Dry Ice.docx
Dry Ice Quiz.docx

We have been using the Echo for just under 1 year.  Some of the most important information I have learned in dealing with equivocals is to be sure the washer manifold is clean, keep an eye on the indicator cells' expiration date (If it is close to the expiration of the lot, the cells tend to be more fragile, and they are not stable for the 24 hours on-board with the stir-ball beating them up.), and last but most important-we use the Technical communications from Immucor for interpretation questions and examples.  It is very helpful in deciphering all the strange little quirks solid phase exhibits. (halos, etc.)  I attempted to attach those Technical Communications, but keep getting errors when uploading.  They are PDF files.  If you e-mail me, I will send them to you that way!  Print them on a color printer, and they will become your new go-to.  They have helped our techs (all generalists) IMMENSELY!  : )
dawn.barding@hshs.org

We have been using the Echo for just under 1 year.  Some of the most important information I have learned in dealing with equivocals is to be sure the washer manifold is clean, keep an eye on the indicator cells' expiration date (If it is close to the expiration of the lot, the cells tend to be more fragile, and they are not stable for the 24 hours on-board with the stir-ball beating them up.), and last but most important-we use the Technical communications from Immucor for interpretation questions and examples.  It is very helpful in deciphering all the strange little quirks solid phase exhibits. (halos, etc.)  I attempted to attach those Technical Communications, but keep getting errors when uploading.  They are PDF files.  If you e-mail me, I will send them to you that way!  Print them on a color printer, and they will become your new go-to.  They have helped our techs (all generalists) IMMENSELY!  : )
dawn.barding@hshs.org

Hi GoodChild, in my previous life I was Process Control Manager for the Australian Red Cross Blood Service...I hear you
 

@Kellimq As a sincere appreciator of process control and flowcharts, whoever designed that document is a genius and has my praise.

GD-CLN-900100.pdf
Hi, We are a multidis non-trauma hospital, with a large (10,000 births/year) maternity hospital. We have found the use of Cryo in the first MTP pack to be advantageous in getting obstetric bleeds under control more quickly. 

Agree, Malcolm.  But if the antibody screen is negative through AHG, but IS crossmatches are rolling off questionable, aren't we obligated identify cold agglutinins, if all other possibilities have been excluded?  Or can we just deem a probable cold agglutinin not of clinical significance?  If "everything else" has been excluded, rouleaux, alloantibodies, etc., but the IS is still "chunky" weak macro or microscopically, would you just do a prewarm crossmatch through 37 degree and AHG phases, and call it good if negative?
Thank you, Scott, for your very valuable input, also!!

Hello All!
I know this subject has been discussed extensively.  It continues to be a source of confusion in my TS, due mostly in part to the lack of solid Blood Bankers (all generalists who rotate through).
Currently, our SOPs for working up suspected cold agglutinins include a "cold screen" at 4 degrees using Immucor Panoscreen I and II, and patient autocontrol.
If Cold Screen is indicative of a cold Autoantibody, a Tube Pre-warm screen is performed, and subsequent panel, if warranted.
This is so confusing to my techs.  Last night I received a call at home from my 2nd shift tech, saying she had a patient coming in for transfusion for one unit of red cells, with no prior history with us, was found to be A+, Negative antibody screen in solid phase on Echo, BUT positive Immediate spin crossmatches.  She then proceeded to tell me she "prewarmed the crossmatches and then they were fine."  She wanted to know how to result the Cold Auto!!!!!!!!!!!!!!!
After swallowing to remove my heart from my throat, I explained that this was not a conclusive "work-up" for a Cold auto.  I talked her through the possibility of Rouleaux (She said she only saw "clumps" not "coins" microscopically); the possibility of an A2 or subgroup, but she assured me the reverse reactions were consistent with A.  I then told her the series of procedures to follow for a suspected cold agglutinin, all of which are in our SOPs.  I suspected Rouleaux, and asked her to follow the saline replacement procedure, explaining that if it was true agglutination, saline replacement would not "correct" it.  She performed saline replacement and the IS crossmatches were as smooth as silk. 
 
I guess my question is, does anyone have any suggestions for making this more clear to our staff?  Also, what are your procedures for identifying a cold agglutinin, or autoagglutinin, both specific and non-specific?  How about a flow-chart to make it easier for techs to determine what to do next?  Any info, SOP, chart anyone is willing to share will be so appreciated right now, and worth its weight in GOLD!!
Dawn

OK-thank you both so much!  Happy Easter!!

I received an email that the written transcript was available on the CMS MLN (Medicare Learning Network). I went to the transcript and was pretty disappointed that my question was not included in the  written transcript. I asked my question late in the 2nd hour and there were many questions that didn't make it to the final transcript. I wanted to see it in writing.
 
Not sure if this link will work for you but I followed this link and typed in IQCP July 15. But since the answer to my question is not written there, the July 15 write up won't help you. You can search using just IQCP in the search box and find work books and flow charts that might help.
 
Medicare Learning Network®
 
We also have an Echo and I had the same concerns about gel and tube panels.