We have a patient that is on repeat transfusion and has had phenotyped (just CDEK) for over 20 years without developing an antibody. He has just been on holiday and has had his top-up in a well known teaching hospital who, despite being provided with full clinical information, EIed the patient unphenotyped blood! The patient has now come back home with an anti-f! We are a remote and rural lab and do not hold huge stocks of blood so now have to manage this patient.

For routine top-ups he is now going to have to have two visits - a pre-sample t be sent away and then com in again for his transfusion. Logistically, this is going to create so much more work and also impact the patient's lifestyle as multiple appointments will cause problems at work My question is though, if he is to go into crisis at any point (bearing in mind that the nearest blood centre is 3 hours away), am I right in thinking the c-, e- blood will be negative for the f-antigen and thus suitable?

Its important to understand that you can use c- or e- units. If one of these antigens is missing the f antigen wil also be negative.

When you order c and e neg blood you will have to wait for a rare donor (CCDEE).

The f antigen is only presen when c and e are present and are expressed on the same protein (coded bij the same gene). An person who is c and e positive can be f positive but it is not nessecery, CcDEe can be CDe/cDE (is f negative (not the same protein)) or can be CDE/cde (is f positive).

Peter

I agree 100% with Peter.

In the literature, however, it is actually quite difficult to find examples of anti-f that have caused anything other than a fairly mild haemolytic transfusion reaction (although it has caused haematurea) and so, if push comes to shove, and your patient needs an urgent transfusion, do not withold blood that you suspect is f positive (although, of course, you will need Consultant advice).

Thank you Peter, although I knew much of your information, it is always good to have a refresher.

Oweee Rh-fan - red and big ack! Jeez...

Yes I know it's either/or was just double checking... hit , instead of /

Everyone else - thanks for the help

Malcolm - I know it's only ever reported as extremely mild but this guy has that much wrong with him that he could probably do without a transfusion reaction on top of it all - no matter how mild He's a 'frequent flier' and we like to do our best for him He's a nice chap

Just don't let anyone give him O neg in an emergency! You know, like all those docs that think that O neg has no antigens!?! I tend to put notes like this into our computer system in case someone not very comfortable in Blood Bank is working the night he comes in as an emergency.

Mabel...I do exactly the same thing with our problematic patients.

BUT, as Brian McClelland MB Chb ND Linden FRCP(E) FRCPath (Consultant Haematologist in the SNBTS) once wrote,

"Transfusion has risks, but bleeding to death is fatal."...

... so, if the patient is bleeding to death, give O Neg and worry about the antibody afterwards.

BUT, as Brian McClelland MB Chb ND Linden FRCP(E) FRCPath (Consultant Haematologist in the SNBTS) once wrote,

"Transfusion has risks, but bleeding to death is fatal."...

... so, if the patient is bleeding to death, give O Neg and worry about the antibody afterwards.

There are more patients dying from the lack of transfusion (because they have to wait for “compatible” units) then that there are dying of transfusion reactions.

BUT, as Brian McClelland MB Chb ND Linden FRCP(E) FRCPath (Consultant Haematologist in the SNBTS) once wrote,

"Transfusion has risks, but bleeding to death is fatal."...

... so, if the patient is bleeding to death, give O Neg and worry about the antibody afterwards.

Thankfully, the great majority of our patients with antibodies aren't in this situation. When they are...hey, that's what they pay the medical director of blood bank the big bucks for - he/she get's to discuss the situation with the attending and decide what they are going to do about it. Which could be transfuse now and take care of the new problems (if any) later. We are more comfortable with the decision to transfuse than most of the attending docs.

My point is that you should take those life-saving risks while fully understanding them whenever possible.

The Anti-f problem has been solved. The patient is on IVIG every 2-3 weeks and a pre-infusion sample showed no evidence of anti-f. Our reference centre has said that the possibility anti-f has been eliminated. I'm not so sure about this though - could it be that it has just fallen to an undetectable level with time, rather than the anti-f coming from the IVIG?

Could be, but, either way, I wouldn't worry about it.

As stated by others, only have to give c- or e-; and obviously, c- much easier to find (would not recommend Rh NEG blood).

Not sure why this patient will have to have 2 visits for ongoing transfusions? Can you not perform their work within 3 days of transfusion?

Also, wondering why you were giving this patient pheno matched blood? And why you would have expected another Hospital to do so? There are only certain scenarios (in my experience) in which one "prophylactically" gives a patient partial or complete phenotypically matched units.

Brenda Hutson, CLS(ASCP)SBB

Not sure why this patient will have to have 2 visits for ongoing transfusions? Can you not perform their work within 3 days of transfusion?

Also, wondering why you were giving this patient pheno matched blood? And why you would have expected another Hospital to do so? There are only certain scenarios (in my experience) in which one "prophylactically" gives a patient partial or complete phenotypically matched units.

Brenda Hutson, CLS(ASCP)SBB

We are a small remote and rural lab and do not have the facilities (or accreditation) to do the workup required.

The patient has phenotyped blood as he is on repeat top up transfusion due to having an auto immune condition. He has been transfused since he is 7 and is now 36 and has blood every 6-8 weeks. Occaionally he goes into crisis and needs a massive transfusion. As we have such a limited supply of blood in stock, and our blood centre is 3 hours away (with a police escort), we have felt it is safer to transfuse him phenotype specific blood to reduce the possibility of him developing antibodies. We didn't want to get into the situation where we had to order blood specifically for him as he had an antibody - this would result in him having to go home and return to receive a transfusion (and he, himself lives 2 hours away from the hospital)

I don't understand what you mean about performing the workup withing 3 days of transfusion...