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Deborah Baudler MS, MT(ASCP) SBB Assistant Professor University of Illinois-Springfield Patchwork Conference April 15, 2014 Investigative Techniques in.

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Presentation on theme: "Deborah Baudler MS, MT(ASCP) SBB Assistant Professor University of Illinois-Springfield Patchwork Conference April 15, 2014 Investigative Techniques in."— Presentation transcript:

1 Deborah Baudler MS, MT(ASCP) SBB Assistant Professor University of Illinois-Springfield Patchwork Conference April 15, 2014 Investigative Techniques in Blood Banking

2 University of Illinois-Springfield

3 UIS CLS Students

4 Identify common problems that occur in day to day blood banking Discuss various techniques for problem-solving Apply new knowledge to case studies for resolution Objectives

5 The science of deduction and analysis is one which can only be acquired by long and patient study... Sherlock Holmes

6 ABO Discrepancies Weak Positive Antibody Screen……no antibody identified Miscellaneous Reactivity showing up on the antibody panel Incompatible Crossmatch when antibody screen is negative Common Problems That Can Occur

7 Cry a little Start over, hoping the problem will just go away Shake the tubes harder Pretend the weak reactions dont exist Call your blood bank supervisor at 2 am to see if she/he is reading a good book Leave it for the next shift to resolve! Common Solutions Available

8 ABO Discrepancy A discrepancy occurs when the red cell testing does NOT match the serum test results In other words, the forward type does NOT match the reverse. What is the discrepancy here? Anti-AAnti-BAnti-DA 1 cellsB cells

9 Recall: the production of ABO antigens is controlled by the genes we inherit ABO forward and reverse reactions are typically very strong: 3+ to 4+. Where do we start? What we do know…. Anti-AAnti-BAnti-DA 1 cellsB cells

10 Most of the time, the problem is technical Failure to add patient plasma Reversed the A 1 and B cells in the rack Reagent contamination Incubation time too short Clot in specimen Interpretations not accurately recorded Discuss the Possibilities

11 Forward vs Reverse Courtesy of School of Health Related Professions University of Mississippi Medical Center Grouping ForwardReverse Missing/WeakExtraMixed Field Missing/WeakExtra A/B Subgroup Disease (cancer) Acquired B B(A) Phenotype O Transfusion Bone Marrow Transplant Young Elderly Immunocompromised Cold Autoantibody Anti-A 1 Rouleaux Cold Alloantibody Rouleaux

12 If you have extra reactivity: Recent Bone Marrow/ Stem Cell Transplant: check medical history Excess protein coating red cells or Rouleaux: Wash red cells and retest Strong cold agglutinin coating cells: Treat cells with 0.01 M DTT Antibody coated red cells causing autoagglutination: can be seen in HDFN. Perform DAT and Incubate cells and wash several times with 37°C saline Reasons for Red Cell Discrepancies

13 Acquired B antigen: occurs in Group A individuals with gram neg sepsis. True group A cells will not agglutinate with patients own Anti-B in plasma Reasons for Red Cell Discrepancies Enzyme cleaves off acetyl group D-Galactose Acetyl group

14 If you have missing or weak reactivity: Subgroup of A: test cells with A 1 Lectin, Anti-A,B and Anti-H Massive red cell transfusion: check transfusion history Cancer or Chemotherapy: require longer incubation period Reasons for Red Cell Discrepancies

15 If you have extra reactivity: Rouleaux: Check for stack of coins and perform Saline Replacement Cold or RT alloantbody: Antibody ID and repeat reverse cells with antigen negative cells Cold or RT autoantbody: Antibody ID and pre-warm plasma and reverse cells in separate tubes, combine and read Reasons for Plasma Discrepancies

16 If you have extra reactivity: Issoagglutinins: Passive ABO antibodies: check recent transfusion history Subgroup of A: A 1 Lectin and antibody ID with A 1 cells Reasons for Plasma Discrepancies

17 If you have missing or weak reactivity: Check age of patient: Newborn: no antibody production until 4 mos Elderly: extend incubation or increase serum/cell ratio Hypogammaglobulinemia: extend incubation or increase serum/cell ratio Chemotherapy or recent Bone Marrow Transplant: check medical history Reasons for Plasma Discrepancies

18 We have extra reactivity on the plasma side Most frequent cause for ABO discrepancy Back to Our Case Anti-AAnti-BAnti-DA 1 cellsB cells

19 In This Case Anti-AAnti-BAnti-DA 1 cellsB cells Patient has never been transfused and is not pregnant 2.Patient is here for elective surgery 3.Antibody Screen is negative, Auto control = 0 4.Checked under the scope, no Rouleaux 5.Whats left to do?

20 1. Recall: 20% of group AB individuals are actually A 2 B. 25% of A 2 B will make an alloantibody called Anti-A 1 2. Test patients red cells with A 1 Lectin. A 2 B will not agglutinate with A 1 Lectin 3. Test patients plasma with several lots of A 1 cells to confirm that the antibody is Anti-A 1 Solution Agglutination No Agglutination A1 cells A2 cells

21 Patient is an A 2 B Pos with Anti-A 1 Solution: Use A 2 reverse cells to eliminate extra reactivity and resolve discrepancy In This Case Anti-AAnti-BAnti-DA 2 cellsB cells

22 2. Weak Positive Screen: Negative Antibody ID Get the Patients Medical History Possible Solutions: Repeat antibody screen and ID by a second method Check expiration dates of reagents Increase serum/cell ratio Increase incubation time Contact the manufacturer How should this be reported? Weak Antibody Activity

23 3. Positive Screen: No specific antibody identified All alloantibodies have been ruled out! Miscellaneous Antibody Activity DCEceK FyaFyb JkaJkbMNSsLua LubISAHGcc +0+nt nt nt

24 What Should You Do?

25 3. Positive Screen: No specific antibody identified Possible Solutions Check lot number of antigrams! Check expiration dates of reagents Repeat antibody screen and ID by a second method Increase serum/cell ratio Increase incubation time Miscellaneous Antibody Activity

26 Highlight positive reactions Check for Dosage Miscellaneous Antibody Activity DCEceK FyaFyb JkaJkbMNSsLua LubISAHGcc +0+nt nt nt

27 Additional Suggestions: Get the Patients Medical History Enzyme panel Check Direct Coombs Perform an Eluate Miscellaneous Antibody Activity

28 For a DAT to become positive: > 200 molecules of IgG on red cell Purpose of an eluate: Removes an antibody thats coating the red cell Concentrates antibody Allows identification of newly forming or weak antibodies Can be positive even when DAT is negative Benefits of an Eluate

29 Miscellaneous Antibody Activity What antibody is detected? DCEceK FyaFyb JkaJkbMNSsLua Lub AHGELU cc +++nt nt nt

30 Possibilities: Perform clerical check on specimen Check agglutination under scope if <2+ Specimen at room temp or out of refrigerator Age of specimen: protein precipitation If Reactivity is 3-4+ Repeat patients blood type Strong Cold Agglutinin Incompatible Crossmatch When Antibody Screen is Negative

31 Other Possibilities: Patient has an antibody to a Low Incidence antigen on unit Unit has positive DAT Most likely Return unit to blood center Solution: Try another unit Incompatible Crossmatch When Antibody Screen is Negative

32 Lets do some Investigating

33 Case 1 71 yr. old woman comes through the ER on a Friday night with a 6 g Hb. While her antibody screen is incubating, you get the following blood type: Anti-AAnti-BAnti-DA 1 cellsB cells

34 ABO discrepancy present Most probably blood type? What should we do next? Thoughts? Anti-AAnti-BAnti-DA 1 cellsB cells

35 Oh No! Next thing you know, her antibody screen comes up positive, YIKES! DCcEeKFyaFybJkaJkbMNSs IS AHG cc nt

36 Lets Do the Cross-out Technique Which Antibodies Could Possibly be Present? DCcEeKFy a FybJk a Jk b MNSs ISAHG cc nt

37 Which Antibody is Present? Antibody ID Results DCEceK FyaFyb JkaJkbMNSsLua LubIS AHG cc +++nt nt +00

38 Antibody identified as Anti-M Anti-M can possess both IgM and IgG components Phenotype patient for M if not recently transfused Test B Neg, M Neg cells with patient plasma Are We Done? Anti-AAnti-BAnti-DA 1 cellsB cells

39 62 yr. old man comes through the ER on a Saturday night with abdominal pain. He is rushed to surgery for a possible bowel obstruction While his antibody screen is incubating, you get the following blood type: Case 2 Anti-AAnti-BAnti-DA 1 cellsB cells

40 Patients medical history indicates he had cardiac by-pass surgery 4 weeks ago and received 3 units of prbcs Perform cross-out technique Which antibodies can not be ruled out? The Antibody Screen Results DCcEeKFyaFybJkaJkbMNSsIS AHG cc nt

41 The Antibody Screen Results Anti-C, e, Fya, Jka, N and Anti-S are not ruled out DCcEeKFyaFybJkaJkbMNSsIS AHG cc nt

42 Conclusion? What is the next step? Antibody ID Results DCEceK FyaFyb JkaJkbMNSsLua LubIS AHG cc +0+nt nt nt nt +00

43 Repeated panel with PeG. Who is the culprit? Antibody ID Results DCEceK FyaFyb JkaJkbMNSsLua LubIS AHG cc +0+nt nt nt nt +00

44 27 yr. old man is medevac to your facility from a small community hospital. The patient has been in a motor vehicle accident and is bleeding internally. He is being prepped for the OR. Case 3

45 So you perform a STAT Type and Screen While the antibody screen is incubating, you record the following results for the blood type: Any problems? Case 3 Anti-AAnti-BAnti-DA 1 cellsB cells 2+ mf 4+

46 The patients antibody screen results are Negative! Now what? The Antibody Screen Results DCcEeKFyaFybJkaJkbMNSsIS AHG cc

47 Patient received: 10 units Group O Negative rbcs 4 Group O Single Donor Platelets Check Medical History

48 Patients ABO discrepancy was due to massive transfusion of out of group blood products. Important Clue: Mixed-field agglutination Information from transferring hospital confirmed that patient was AB Positive What blood type of rbcs should be transfused? Resolution

49 You did it!


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