Years ago, I had a short blurb (maybe from Lab Medicine?) on how to transfuse patients with incompatible blood as safely as possible.  It included the example of liver transplants and talked of "saving the best wine for last".  Does anyone have a reference that covers how to transfuse (of course avoiding it unless life-saving) in the presence of multiple antibodies or antibodies to high frequency antigens?  We have a patient with anti-S and anti-Dib.  I have some plans for if a life-threatening emergency arose but would like to have a reference.

This is almost certainly NOT the paper that you wanted referenced, but it may help in an emergency.

Win N, Needs M, Thornton N, Webster R, Cheng C.  Transfusion of least-incompatible blood with intravenous immunoglobulin plus steroids cover in two patients with rare antibody.  Transfusion 2018; 58: 1626-1630.  (DOI: 10.111/trf.4648).

1 hour ago, Malcolm Needs said:

This is almost certainly NOT the paper that you wanted referenced, but it may help in an emergency.

Win N, Needs M, Thornton N, Webster R, Cheng C.  Transfusion of least-incompatible blood with intravenous immunoglobulin plus steroids cover in two patients with rare antibody.  Transfusion 2018; 58: 1626-1630.  (DOI: 10.111/trf.4648).

Yes, that is valuable for the treatment advice.  For the transfusion decisions, my plan is to say, "don't unless necessary", then, if there are enough compatible units and Ab titer is very high, start with a couple of compatible units. Once antibody has been bled out, then use random units and, if you can guess when the last few units will be given, make them the more compatible ones to reduce the RBC destruction in the coming days.  If titer is lower or there are few to no compatible units, start with random units and try to fill the patient up with the (more?) compatible units at the end.  Maybe with sufficient immune suppression as your article suggests, we wouldn't have to try to guess when the last few units will be transfused.  We could keep the compatible ones for single unit transfusions over the ensuing days.