How does everyone handle transfusing patients with warm autos, and do not perform adsorptions? We have a handful of patients with warm autos. We send them out to our reference lab the first time to see if they have any underlying allos, and to get their phenotype. From there,we give them antigen-negative blood for the corresponding allo, and we honor their Rh and Kell phenotype, so hopeully they won't produce any antibodies. We extend crossmatch and label it least incompatible. We require the physician to sign- which they always do. I just want to see what other sites do who also don't perform adsorptions.

Shelly Niedzwiecki, MT (ASCP)

We do the same as you but we don't extend the XM, we send the workup out every 72 hours.

I interpreted extended xm as AHG xm. Hmm.

We do the same, and send out a specimen from the same patient every six month for adsorption to the ref. lab.

Hi Shelly,

We do the same, however, we recently changed the last step in that we no longer need a physicians signature.

Instead of the signature, we enter a charted comment in the patients profile that allows the blood banker to call

this warm autoaby as a critical result to the RN. Any units that are least incompatible due to a warm auto or HTLA

are considered critical results.

What does "extend crossmatch" mean?

I would like to know what "least incompatible" means, following Lawrie Petz's publication of 2003 (Petz LD. "Least incompatible" units for transfusion in autoimmune hemolytic anemia: should we eliminate this meaningless term? A commentary for clinicians and transfusion medicine professionals. Transfusion 2003; 43: 1503-1507.).

I always thought that least incompatible was like being a little pregnant . . . We don't do least incompatible. I transfuse warm autos - I phenotype them for Rh on the initial encounter and provide Rh identical after that. Once they have been transfused I can no longer autoabsorb so I must forward recurring requests to the reference lab.

We send to ref lab every 3 days like any other patient. We have had warm auto patients make allo antibodies. How do you do extended xm (AHG?) on warm auto? Isn't reaction positive at Coombs?Any unit in our facility that can not be XM by standard methods is released only on emergency release (dr takes responsibility).

I would like to know what "least incompatible" means

Ah, yes...just a little something to make the BB feel better.

Ah, yes...just a little something to make the BB feel better.

Exactly......and the patient????????????????!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

The blood center we deal with uses adsorbed plasma to find compatible xm'd units. Is this that so much safer than using "least incompatible units"?

The blood center we deal with uses adsorbed plasma to find compatible xm'd units. Is this that so much safer than using "least incompatible units"?

Yes. The auto-antibody is adsorbed out, leaving alloantibodies that can then be identified and antigen positive blood cross-matched.

In our case, we split the patient's plasma into three aliquots. One of these is adsorbed using R1R1 papain-treated red cells, one with R2R2 papain-treated red cells and one with rr papain-treated red cells. All of these will adsorb out the auto-antibody, but, if, for example, the patient has an underlying anti-c, the R2R2 and rr red cells will adsorb this out too, but the R1R1 red cells will not, and so the anti-c will be detected in the aliquot adorbed with the R1R1 red cells.

The red cells are also typed for the other common antigens and then chosen for their usefulness. One, for example, will be K+k+, whilst the other two will be K-k+, one, at least, will be Jk(a+b-), and another, at least, will be Jk(a-b+) and so on. Obviously, we do not worry about the M, N, S, s, Fy(a) and Fy( antigens of these cells, as they are papain-treated, and so these antigens will be denatured, so any antibodies against these antigens will remain in the adsorbed plasma.

Of course, if the patient has an underlying antibody to a high-frequency antigen, such as anti-k, anti-Vel, anti-Lan, etc, this antibody will also be adsorbed out. This is why we always advise that blood cross-matched with adsorbed plasma should be transfused slowly, and the patient monitored extremely carefully, just in case - but it is certainly safer than "least incompatible units".

in-vivo crossmatch, Malcolm.

Well, to a certain extent, I must agree with you Liz, but it is less of an in vivo cross-match than giving "least incompatible"!

Absolutely....

Even if we use xm compatible with autoabsorbed plasma we do the in vivo(my Pathologiist insists) and we have the pts MD sign a release for incompatible rbcs (since using the plasma "neat" the xm is incompatible).

in-vivo crossmatch, Malcolm.

Yes, an in-vivo crossmatch is how I would prefer to transfuse these units. I have not gotten too beginning this procedure at this hospital yet (been super here about 1 1/2 yrsl---- too many other upper mgmt level priorities ahead of beginning new procedures).

In the meantime we require doctors to sign emergency release form saying the patient clinically is in critical need of the blood. We have several reasons listed where the reason for the emergency release is a check off box with canned comment: IE: Antibody Unidentified, units being transfused may later be found to be incompatible. OR Crossmatch not done by standard means, please monitor patient closely during transfusion for signs of imcompatibility.

Etc.

And our reference lab uses the same technicque for autoabsorption Malcom. We insist on this procedure for getting compatible units every 3 days (as is normal, day of draw being day 0). Only give least incompatible when ARC Ref lab says that is all they can provide (which is very rare). Least incompatible would also require a emergency release.