Solving Blood Bank Case Studies, is easy as… - MOascls-mo.org/documents/Spring...
Transcript of Solving Blood Bank Case Studies, is easy as… - MOascls-mo.org/documents/Spring...
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Solving Blood Bank Case Studies, is easy as…
Deborah Baudler MS, MT(ASCP)SBB
ASCLS-MO/STL CLMA Spring Conference
April 6, 2016
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Objectives
• 1. Identify common problems that occur in day to day blood banking
• 2. Discuss various techniques for problem-solving
• 3. Apply new knowledge to case studies for resolution
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You have been called to join this elite investigative team of Super Immunohematologists!
ARE YOU READY?
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“The science of deduction and analysis is one which can only be acquired by long and patient study...”
Sherlock Holmes
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The tricks to problem-solving…
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Having the Knowledge and Resources
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Let’s Narrow Down the List…
• ABO Discrepancies
• Weak Positive Antibody Screen……no antibody identified
• Miscellaneous Reactivity showing up on the antibody panel
• Incompatible Crossmatch when antibody screen is negative
• Antibody that doesn’t “behave” as it should
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The most common problem is…
• Telephone rings so you didn’t notice that the A1 and B cells were reversed in your rack
• Red cell suspensions are too heavy or too light
• Reagents expired or contaminated?
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Other possibilities…
• Got interrupted and forgot to add patient plasma
• In a hurry… forgot to set timer so incubation time too short or too long
• Didn’t notice a fibrin clot in specimen
• Interpretations not accurately recorded
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Many times, the solution is easy…
• Start over, hoping the problem will just go away
• Shake the tubes harder
• Rock, paper, scissors…
• Pretend the weak reactions don’t really 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!
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Sometimes the problems are real, now what?
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• For complete identification of antibodies:• 1. Rule out using homozygous cells
• 2 Exceptions: • Anti-K [1 heterozygous cell]• Anti-C and Anti-E when Anti-D [2-3 heterozygous cells]
• 2. Consider the phases of reactivity
• 3. Consider the strengths of reactivity
• 4. Is there a matching pattern?
• 5. Is everything else ruled out?
• 6. Is there any extra reactivity that is not accounted for?
• 7. Is the 0.05 p-value or 95% confidence limit met?
• 8. Is the patient antigen negative for corresponding antibody(ies)?
Let’s review a few rules…
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Let’s explore some Case Studies…
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Case 1
• 82 yr. old woman arrives by ambulance from local nursing home
• Medical history: Type 1 diabetic, slipped and fell after dinner
• Hgb is 6.8 g/dl, Hct is 20%
• X-rays reveal a broken right hip
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Case 1
• ER doctor orders a 2 unit crossmatch STAT!
• Her blood type results:
• What’s her blood type?
Anti-A Anti-B Anti-D A1 cell B cell
0 4+ 3 + 4+ 1+
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Oh No!
D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc
1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √
2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √
3 0 + + 0 + 0 + 0 + + + 0 + + 2+ 2+ nt
• Next thing you know, her antibody screen comes up positive, YIKES!
• Let’s do the Cross-out Technique
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Case 1
• Which Antibodies Could Possibly be Present?
D c E e K Fyb Jka Jkb N S s IS AHG cc
1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √
2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √
3 0 + + 0 + 0 + 0 + + + 0 + + 2+ 2+ nt
C Fya M
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The panel results… for Case 1?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub IgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + W+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + + + 0 0 + 1+
7 0 + 0 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 + 0 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 0
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + + + 0 0 + w+
PC 0
Let’s do the cross outs
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The panel results… for Case 1?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub IgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + W+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + + + 0 0 + 1+
7 0 + 0 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 + 0 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 0
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + + + 0 0 + w+
PC 0
M
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What do we know…
•Antibody identified as Anti-M and patient phenotypes M Neg
•Anti-M can possess both IgM and IgG components
•IgM antibodies can cause ABO discrepancies
•To resolve discrepancy: test group B, M Neg cells with patient plasma
Anti-A Anti-B Anti-D A1 cells B cells
0 4+ 3+ 4+ 0
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Case 2
D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc
1 + 0 + 0 + 0 + + + 0 0 + + 0 0 0 √
2 + 0 + + 0 + 0 + 0 + + + 0 + 0 0 √
3 0 + + 0 + 0 + 0 + + + 0 + + 0 0 √
• 33 yr. old woman is admitted for delivery of her 3rd child
• Blood type is A Negative and antibody screen is currently Negative
• She has a history of an anti-K
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Case 2
• It’s been over 24 hrs. and labor has not progressed after her membranes ruptured at home
• The OB doctor requests 2 units of blood to be crossmatched since he is prepping for a C-section
• One of the 2 K-negative units is incompatible in the Coomb’sphase of testing
• A DAT is performed on the reactive unit and it is negative
• What should you do next?
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The panel results… for Case 2?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 0
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0
PC 0
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What next?
• Find 2 more Cw select cells to run to confirm antibody ID
• Cw results in a single amino acid change most often found on the RhCe protein• Cw is located on the first extracellular loop of the RhCE
gene
• Anti- Cw may show dosage
• Will it be hard to find a 2nd compatible unit?
Transfusion. 2004 Nov;44(11):1663-73.
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So far so good!
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Case 3
• It’s 8 pm on a quiet Friday night in St. Louis
• Next you hear over the loud speaker… “phlebotomy to Trauma 1”
• 38 yr. old male arrives by ambulance, bleeding from multiple stab wounds, impacting several internal organs
• The ER doctor orders 2 O Neg uncrossmatched units after phlebotomy draws his specimen
• The specimen arrives with an order to Type and Cross 5 units of prbcs and thaw 2 units of FFP to be transfused during surgery
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Case 3
D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc
1 + + 0 0 + + + 0 + + 0 + + 0 0 1+ nt
2 + 0 + + 0 0 0 + 0 + + + 0 + 0 0 √
3 0 + + 0 + 0 + + + 0 + 0 + + 0 0 √
His Type and Screen results are below:
Anti-A Anti-B Anti-D A1 cells B cells
0 0 4+ 4+ 3+
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The panel results… for Case 3?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+
2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0
PC 0
Let’s do the cross outs
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The panel results… for Case 3?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+
2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0
PC 0
Everything is ruled out, now what?
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What Should You Do?
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Things to consider when you have weak reactivity…• Get the Patient’s Medical History
• Possible Solutions: • Check lot number of antigrams!• Repeat antibody screen and ID by a second method• Check expiration dates of reagents• Increase serum/cell ratio• Increase incubation time• Perform an enzyme panel• Contact the manufacturer
• How should this be reported?
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The panel results… for Case 3?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + W+
2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 1+
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 1+
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0
PC 0
Highlight the positives, looking for a pattern or dosage
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Additional suggestions…
• Medical history confirmed patient had received 2 units of red cells 2 months ago due to a drive-by shooting
• The antigram and reagents were ok
• The panel was repeated using additional drops of serum and PEG, no improvement
• An enzyme panel was completely negative
• We tried all the above suggestions and still NOTHING! UGH!!
• Let’s try an eluate!
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• When a patient forms a new antibody, it attaches to transfused cells
• For a DAT to become positive: >200 molecules of IgG on red cell
• Purpose of an eluate:• Removes an antibody that’s coating the red cell
• Concentrates antibody
• Allows identification of newly forming or weak antibodies
• Can be positive even when DAT is negative
• In this case the DAT was weak positive
Benefits of an Eluate
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The panel results… for Case 3?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub
IgG
eluate cc
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 1+ nt
2+ + 0 0 + 0 0 + + 0 + 0 + + + + + 0 + + + + 0 + 0 + 1+ nt
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0 √
4 + 0 + 0 + + 0 0 + 0 + 0 + 0 0 + + 0 0 + + + 0 + 0 + 0 √
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0 √
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 2+ nt
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt
80 0 + 0 + + 0 + + 0 + 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + 0 + 2+ nt
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 0 √
PC
An Anti-Fya was identified. Case solved!
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After surgery…
• The patient received 2 units of Fya neg blood and was transferred to the county jail after he recovered from his wounds.
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• 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 4
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• 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 4
Anti-A Anti-B Anti-D A1 cells B cells
2+mf 2+mf 2+mf 4+ 4+
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• The patient’s antibody screen results are Negative!
• Now what?
Case 4
D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc
1 + 0 + 0 + 0 + 0 + 0 0 + + 0 0 0 √
2 + 0 + + 0 + 0 + 0 + + 0 0 + 0 0 √
3 0 + 0 0 + 0 + + + + + + + + 0 0 √
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• Check Medical History
• Patient received:
• 10 units Group O Negative rbcs
• 4 Group O Single Donor Platelets
Case 4
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• Patient’s 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 to Case 4
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Ready for Another Case?
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Case 5
• 22 yr. old sickle cell patient
• Transfusion history: received numerous units of red cells since the age of 14 yr.
• She is in the out patient center awaiting a 2 unit transfusion
• Her blood type is A Positive and she has been phenotypically matched for Rh and K.
Anti-C Anti-c Anti-E Anti-e Anti-K
4+ 3+ 3+ 4+ 0
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Case 5
D C c E e f K Fya Fyb Jka Jkb M N S s Gel
AHG
1 + + 0 0 + 0 0 + + + 0 0 + + 0 0
2 + 0 + + 0 0 + 0 + 0 + + + 0 + 0
3 0 0 + 0 + + 0 + 0 + + + 0 + + 2+
• Her antibody screen comes up positive!
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The panel results… for Case 5?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 0
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 2+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 2+
PC 0
Let’s do the cross outs
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The panel results… for Case 5?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 0
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 0
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 2+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 2+
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 2+
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 2+
PC 0
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Resolution for Case 5?
• The f antigen is expressed when c and e are made by the same gene
• It is present on all R0 (Dce) and r (dce) haplotypes
• Anti-f is often a component of anti-c or anti-e
• It is clinically significant and can cause mild HTR and mild HDFN
• Patients with anti-f can be transfused with c or e neg. red cell units• R1R1 or R1R2 will be given c negative, R2R2 will be given e negative
• Our sickle cell patient safely received 2 c negative units without any complications
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Case 6
• 56 yr. old man with a history of ITP (Idiopathic Thrombocytopenia Purpura)
• Hgb: 7.5
• Platelets: 10,000
• Physician orders 2 units of red cells
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Case 6
D C c E e K Fya Fyb Jka Jkb M N S s IS AHG cc
1 + + 0 0 + + + 0 + + 0 + + 0 0 2+ nt
2 + 0 + + 0 0 0 + 0 + + + 0 + 0 2+ nt
3 0 + + 0 + 0 + + + 0 + 0 + + 0 0 √
His Type and Screen results are below:
Anti-A Anti-B Anti-D A1 cells B cells
0 4+ 3+ 4+ 0
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The panel results… for Case 6?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 3+
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 3+
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 3+
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 3+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + + 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 3+
PC 1+
Let’s do the cross outs
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The panel results… for Case 6?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua LubIgG
Gel
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 3+
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 3+
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 3+
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 3+
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 0
6 0 0 + + + 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 0
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 0
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 0
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 3+
PC 1+
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What to do next?
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Select Cell Panel for Case 6
Vial D C c E e C
w
K k K
p
a
Js
a
F
y
a
F
y
b
Jk
a
Jk
b
L
e
a
L
e
b
P1 M N S s L
u
a
X
g
a
Pt
AHG
1 0 + + 0 + 0 + + 0 0 + 0 + 0 0 + + + + + 0 0 0 0
2 0 + + 0 + 0 0 + 0 0 + + 0 + + 0 + + 0 0 + 0 + 0
3 0 0 + + + 0 0 + 0 0 0 + 0 + 0 + + 0 + 0 + 0 + 0
4 0 0 + + + 0 0 + 0 0 0 + 0 + 0 + + 0 + 0 + 0 + 0
•To rule out Anti-E and Anti-C when Anti-D is present
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Anti-D when the Patient is Rh Positive?
• How is that possible?
• Transfusion history: received 6 B positive units in last 3 years
• No bone marrow or stem cell transplant
• Medications: WinRho
• What’s that?
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Resolution for Case 6
• Large dose of anti-D
• Used to treat patients with ITP in Rh Positive patients along with corticosteroids
• Pathophysiology: anti-D will attach to red cells and trick spleen into removing them instead of antibody-coated platelets
• Transfusion requirements?
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Case 7
• A 30 yr. old man admitted for a relapse of acute leukemia.
• Transfusion history: Received 2 units of leuko-reduced packed red blood cells without incidence last year.
• On this admission, the physician orders 2 units of red cells since his hematocrit is 18%.
• 3 days later the patient’s Hct is 15% with no signs of bleeding. The patient receives 2 more crossmatch compatible units.
• His type and screen results are below:
Anti-A Anti-B Anti-D Rh ct. A1 cells B cells SCIAHG
SCII AHG
SCIIIAHG
4+ 0 3+ 0 0 2+ 0 + 0 + 0 +
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Case 7
• During the transfusion of the fourth unit, the patient develops fever, chills and hemoglobinuria.
• A transfusion reaction workup is ordered.
• The post-transfusion specimen was slightly icteric after centrifugation.
• The post-transfusion specimen DAT is weakly positive with Anti-IgG and Anti-C3d.
• What should be done next?
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The panel results… for Case 7?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub
Poly
AHG
eluate
cc
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+ nt
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0 √
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 2+ nt
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 1+ nt
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+ nt
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0 √
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+ nt
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 1+ nt
PC
Let’s do the cross outs
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The panel results… for Case 7?
Vial D C c E e f Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub
Poly
AHG
eluate
cc
1 + + 0 0 + 0 + 0 + 0 + 0 + + + + 0 0 + 0 + 0 0 + 0 + 2+ nt
2+ + 0 0 + 0 0 + + 0 + 0 + 0 + 0 + 0 + + 0 + 0 + 0 + 0 √
3+ 0 + + 0 0 0 0 + 0 + 0 + 0 + + 0 0 + + 0 + 0 0 0 + 2+ nt
4 + 0 + 0 + + 0 0 + 0 + + 0 0 0 + + 0 0 + + + 0 + 0 + 1+ nt
50 + + 0 + + 0 0 + 0 + 0 + 0 + + + + 0 + + 0 + + 0 + 1+ nt
6 0 0 + + 0 0 0 0 + 0 + 0 + + 0 0 + + 0 + + 0 + 0 0 + 0 √
7 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + 0 + 0 + 2+ nt
80 0 + 0 + + 0 + + + 0 0 + 0 + 0 + 0 + + + 0 + 0 0 + 0 √
9 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + 0 0 + 2+ nt
10 0 0 + 0 + + 0 0 + 0 + 0 + + 0 + 0 0 + 0 0 + + + + + 2+ nt
11 + + + + + + 0 0 + 0 + + + 0 + + + 0 + + + 0 + 0 0 + 1+ nt
PC
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Case 7
• Kidd antibodies can bind complement, so weak reactivity can be enhanced with Polyspecific AHG
• Common cause of delayed transfusion reactions due to rapidly decreasing titers
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Case 7
• Both units phenotyped Jka positive
• 91% of Blacks and 77% of Caucasians are Jka
positive
• Jka and Jkb are well developed at birth
• Kidd antigens are not destroyed by enzymes or DTT
• Kidd antibodies are IgG
• Anti-Jka and Anti-Jkb reactivity can be enhanced by PEG, LISS, enzymes or by increasing the serum to 4 drops
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Congratulations! You are now among the Elite Group of Blood Bankers!
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Additional Blood Bank Resources
• Blood Bank Guy [Dr. Joe Chaffin] = bbguy.org
• Transfusion Medicine Question of the Day• http://transfusionnews.com/path-questions/
• One of the editors and co-founders is Dr. Ronald Jackups [WUSTL]