Yes, I saw the response that it was 4+ at 37 and IgG which obviously does make it clinically significant.........I just thought my "4 degrees" body temperature statement was funny....

Oh Malcolm.....why have you bestowed upon me your sense of humor???????

Whoah, Mr. Needs, apparently I was misinterpreted. I wasn't trying to sound like a jerk or anything.

I guess I was trying to remain open in my mind as to what could be going on with an incompatibility detected after seeing a patient specimen for the fifth time. 1/10 units (assuming 2 units per transfusion "event") incompatible is a little different than 1/1000. I'm not sure what your threshold for "low incidence" is, but I was thinking a little lower than 10%. But yes, I assumed a lot and didn't qualify that, so for that I apologize.

I often find myself paying for my sense of humor (or, as you would probably argue, complete lack thereof).

jhodam, I didn't think you sounded like a jerk at all. I think you sounded like a professional blood banker trying to take the best care he/she can of his/her patient. That's what this forum is about. Learning from other Techs who have already experienced your "issue".

I will say one thing.....you posted "an incompatiblity detected after seeing a patient specimen for the fifth time". After presumably 4 previous transfusions it is most certainly not unexpected to detect antibodies! Low, high incidence, whatever.

I normally stay our of the Reference area but I have a couple of questions;

First, how many units were crossmatched and how many were incompatible?

Since the initial detection was 4+ with an IS XM was an IS panel ran? Were the cells from the unit washed at least once prior to the testing? If so have the cells washed 4 -6 times and retested? As a transfusion service, if I were to receive this patient I would like to know as much as possible and a card stating they have a low freq AB is not terribly enlightening.

Apparently I missed pages 2 and 3 for this thread before I resonded and most of my questions were actually answered. One thing I realized quite some time ago is that Transfuison Medicine like any other science dealing with biological sciences is a very inexact science. If we want black and white we should have become engineers. I don't think I would have too much trouble making a note of this in the patient's bloodbank computer record, finding the required number of compatible untis and moving on. At least with this one you could get by with IS crossmatches.

Edited January 30, 201015 yr by John C. Staley

I normally stay our of the Reference area but I have a couple of questions;

First, how many units were crossmatched and how many were incompatible?

Since the initial detection was 4+ with an IS XM was an IS panel ran? Were the cells from the unit washed at least once prior to the testing? If so have the cells washed 4 -6 times and retested? As a transfusion service, if I were to receive this patient I would like to know as much as possible and a card stating they have a low freq AB is not terribly enlightening.

I fully accept, John, that a card stating the patient has an antibody directed against a low frequency antigen is not terribly enlightening, but for reasons given by me in an earlier post in this thread, there are very good reasons why, often, nothing more specific can be written on such a card.

That having been said, however, it would serve to alert a Blood Bank of the potential, albeit tiny, danger of issuing blood by electronic issue (EI). I fully accept that there must have been hundreds of patients with such antibodies who have already been safely and successfully transfused with EI blood, but, one day, it is going to happen that such a transfusion will result in a haemolytic transfusion reaction (possibly fatal, but more likely resulting in renal failure, but not a fatality), and if we know that a patient has such an antibody, a serolgical cross-match should be performed, so that this tiny gamble is not taken.

It's the old thing, "If it were my mother....".

:):)

Hi Folks,

Been on Hols to Canada and missed what is a fascinating discussion.

Have to agree with Malcolm - you know about it - you must be duty bound to warn others with an alert card. Hopefully the patient will not need more and won't go to a hosp that he/she is not known and recieve a electronically crossmatched unit. I go with what if this was me? I wouldn't like to be part of an unwitting experiment. Would probably be OK, but could go horribly wrong (minute percentage percent would still not be acceptable to me).

This is what makes bloodbank so facinating and keeps us at the coal-face.

Regards

Eoin

Hi Folks,

...Hopefully the patient will not need more and won't go to a hosp that he/she is not known and recieve a electronically crossmatched unit. I go with what if this was me? I wouldn't like to be part of an unwitting experiment. Would probably be OK, but could go horribly wrong (minute percentage percent would still not be acceptable to me).

But there is a bigger picture here. The criteria for electronic and IS crossmatch are the same: a negative antibody screen. Let's pretend that this unit had been issued electronically and the patient had a reaction. An example of a root cause investigation (or at least how I would perform it using 5 whys):

Why did the patient receive incompatible blood? Because the units were electronically crossmatched.

Why were they electronically crossmatched? Because the antibody screen was negative, the patient was eligible for electronic crossmatch.

Why was the antibody screen negative? Because the antibody present did not react with the screen cells used.

Why didn't the antibody react with the screen cells used? Because the antibody was to a low-incidence antigen that was not present on the screening cells used.

Why wasn't the antigen present on the screening cells? Because by nature, low-incidence antigens are not found on very many screening cells.

So how would you put together a corrective/preventative action plan? You can't screen for every potential RBC antibody possible because (1) your cells are not typed for all possible RBC antigens; (2) it would be irresponsible to more patients to try to rule out all potential antibodies possible. The only way to do it is to abandon both the electronic and the IS crossmatch and do an AHG crossmatch for every patient with every unit. Does anybody work at a facility that does 100% AHG crossmatches? Even the AHG crossmatch has limitations that could result in an incompatible transfusion.

But there is a bigger picture here. The criteria for electronic and IS crossmatch are the same: a negative antibody screen.

.

I know from where you are coming heathervaught, but that statement is not absolutely true (or, at least, it is not true for the UK Guidelines).

A patient is still eligible for an electronic issue of blood or an "immediate spin" cross-match if the antibody detected is NOT clinically significant. For example, if wide thermal amplitude "cold" auto-antibody is present or, come to that a warm auto-antibody is present, but extensive serological work shows that no clinically significant atypical alloantibodies are present (or as much as it is possible to say), then the patient would still be eligible for, at the very least, an IS cross-match, on the grounds that a serological AHG cross-match would almost certainly be incompatible anyway.

I know I am being pedantic here, for which I apologise, but needs must (if you will forgive the (intended) pun!

:redface::redface:

I understood your post and followed your logic, Heather. So, in the end, was your conclusion that the patient should not be given a card with the antibody information?

What would be the harm of giving the patient such a card? (Aside from the previously-discussed topic of "breach of confidentiality.") It can't harm.....and it might help. In this one patient's unusual situation, go the extra step of doing a complete crossmatch.

I would liken it to a card that says the patient has a very uncommon allergy to some particular medication. In that one unusual situation, research the PRD (Physician's Desk Reference) manual and make sure whatever medication you prescribe for the patient doesn't belong to that drug derivative (or "drug family", or whatever the proper terminology is.)

I understood your post and followed your logic, Heather. So, in the end, was your conclusion that the patient should not be given a card with the antibody information?

What would be the harm of giving the patient such a card? (Aside from the previously-discussed topic of "breach of confidentiality.") It can't harm.....and it might help. In this one patient's unusual situation, go the extra step of doing a complete crossmatch.

I would liken it to a card that says the patient has a very uncommon allergy to some particular medication. In that one unusual situation, research the PRD (Physician's Desk Reference) manual and make sure whatever medication you prescribe for the patient doesn't belong to that drug derivative (or "drug family", or whatever the proper terminology is.)

Agreed.

That was sort of what I was getting at in my earlier post.

:redface:

Our electronic crossmatch criteria are a bit tighter. We use it only in times of massive transfusion, i.e. 10 units or greater. The thinking is that the previous 10 units were all IS crossmatch compatible, so that gave an opportunity to find situations like the one discussed.

I do have one question, was the tube crossmatch performed with everything prewarmed? I usually find that if I prewarm the patient plasma, and cell suspension for at least 5 minutes, things tend to present a better in vivo picture if you are having cold reactive issues. Then I also might re-warm the crossmatch, as it does spin at room temp.

I also agree with your reference lab, as it is a huge time and materials issue to ID every low incidence and even more so one that seems cold reactive.

As far as the card goes, any extra information in Blood Bank helps. It is the lack of info that causes issues. Case in point, a patient with history of antibodies arrived here and was transfused, she was an altered mental status patient who was very anemic on arrival and so did not mention her antibodies ( yes two actually) and we transfused her ( E, Fya) and surprise she had a lovely delayed hemolytic reaction. I would have loved or her to have had a card with her ID.

Edited February 4, 201015 yr by LaraT23
spelling correction, typos

We issue electronic crossmatched units on any patient without some previous "issue" and with a current negative antibody screen. If we detect anything potentially present,,,,low incidence, cold, warm, etc then we automatically AHG crossmatch units.

Are we potentially missing some clinically significant low feq antibodies? Most assuredly. But, as previously posted...there is no possible way to screen every potential recipent for all the low incidence antibodies.

I don't see a problem with issuing a card to the patient, but the effective use of this is dependant upon so many external factors to be successful...but if it prevents your patient from receiving even one unit of incompatible blood, it is worth a try. See this thread: http://www.bloodbanktalk.com/forum/showthread.php?t=3972&highlight=card. You might benefit more from bringing up the topic with colleagues in your area to determine the most effective way to handle a patient like this. Does your blood supplier organize meetings between hospitals? We call it a Technical Advisory Committee. You might also check with your local State Association of Blood Banks and ask if this is a topic that can be addressed.

You have brought up some good points and suggestions, Heather. The Technical Advisory Committee can be a great place to bring up this type of subject.

Yes, we have them over here in the UK too.

There are two types. The first is the Technical Advisory Group for Transfusion Science, run by the Hospital Chief Biomedical Scientists, but with input from the NHSBT (Hospital Liaison, a Consultant Pathologist to give clinical input and the Reference Service Manager). The second is a User Group, run by the NHSBT. These are some of the most useful meetings I attend.

In addition, the various Regional Transfusion Committees run Education Days each year.

This is all in addition to the vaarious education days run by the Special Interest Groups of the British Blood Transfusion Society, and various meetings held by the Institute of Biomedical Science, The Royal College of Pathologists and the Severe Hazards of Transfusion Scheme (SHOT), to name but a few.

:D:D:D:D